← Return to forms & documents WSIB Intake Form Name * First Name Last Name Accident Information Date of Loss MM DD YYYY Occupation Length of time at current job SIN Are you currently receiving treatment from another health care professional? Yes No If yes, what treatment are you receiving? EMPLOYER INFORMATION Employer Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisor Name First Name Last Name Supervisor Phone (###) ### #### Fax (###) ### #### AGREEMENT By agreeing, you confirm that: * I acknowledge that any treatment fees not covered by WSIB will be my responsibility. Agree Disagree Thank you!We’ve received your form, see you at your appointment!
