If you're self-employed as a partner or a proprietor (i.e., you’re not automatically covered by the Workers Compensation Act), you can use this form to apply to register with us and to apply for Personal Optional Protection, whether or not you employ workers.

You can easily apply for coverage online – it is quick and convenient. When you apply online you can save your application in progress and return to complete it at another time, view your application status, and once submitted you’ll receive a confirmation number by email.

Alternatively, this form can be printed and completed by hand, or it can be downloaded and completed digitally in Adobe Acrobat. If you don’t already have Acrobat on your computer, you can download Adobe Acrobat Reader, a free app, from get.adobe.com/reader.

Please note the form’s functionality will not work properly if the form is opened in an internet browser such as Microsoft Edge or Google Chrome.

To complete and submit the form digitally:

1. Click the Download PDF button. The form will be copied to the Downloads folder on your computer hard drive.
2. Open the form in Acrobat by going to your Downloads folder and right-clicking on the PDF file. Select Open with > Adobe Acrobat Reader.
3. Type your information in the form and attach any additional documents.
4. Save your form, then click the Submit button at the end of the form.
5. An email will pop up. Ensure your completed form is attached, then click Send.