Workers’ Compensation Board (WCB) Information Form

Name*
First Last
Email*
Phone
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of injury*
DD slash MM slash YYYY
Date of form A/B
DD slash MM slash YYYY
MSI Number
Claim Number
Employer
Employer Contact Name
First Last
Employer Contact Phone
Employer Contact Fax
WCB Case Worker
First Last
WCB Case Worker Phone