By completing this form, you authorize WorkSafeBC to access your personal information related to your injury and employment.

Want to submit your form online?

1. Download and complete the fillable PDF in Acrobat Reader (a free application), and save it. Alternatively, you can print the form, fill it out manually, and scan and save it.
2. Submit it to us by selecting Upload form and following the instructions. This tool will add the form directly to your claim file.

For more information, including instructions on how to add your electronic signature, see Complete & submit fillable PDF forms online.