To be completed by worker or surviving dependent for third party or out-of-province claim.

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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.