IMPORTANT ELEMENTS OF THIS FORM

1. Request for information to conduct a preliminary calculation of your Earnings Basis

2. Payment Agreement

• Please complete this form and provide the requested information pertaining to your request for a recalculation of your Earnings Basis (Compensation Rate).
• Also, please review and sign the following Payment Agreement, which sets out the payment terms for our work pertaining to your request.

Limitations & Disclaimer

By signing this document I agree that I have read and understood the contents of the entire document. I further agree to allow wsibsettlements.com to perform a recalculation of my Compensation Rate (Earnings Basis) for the above-noted claim, to determine if it is appropriate for me to submit a formal request to the Workplace Safety & Insurance Board (WSIB) to recalculate my Earnings Basis. I further agree that this does not, in any way, constitute legal advice and/or any agreement or undertaking that wsibsettlements.com will have any direct dealings or represent me with the WSIB. I also agree to allow wsibsettlements.com to dispose of any and all documents I am providing as soon as the recalculation has been completed. 

Service Fee

A 10% (ten percent) Service Fee is required to perform calculations to your Earnings Basis previously calculated by the Workplace Safety & Insurance Board (WSIB) pursuant to the Workers' Compensation Act (WCA) of Ontario and for the preparation of a formal request to be submitted by you directing the Workplace Safety & Insurance Board (WSIB) to proceed with said recalculations. 

The Service Fee shall be based upon the results of said recalculation by the Workplace Safety & Insurance Board (WSIB) and the payment of the entire benefits paid to you, such as any and all arrears payments, including interest on said payments by the Workplace Safety & Insurance Board. 

 

Payment Agreement

I understand and agree that I shall immediately submit to WSIB SETTLEMENTS a copy of any correspondence I receive from the Workplace Safety & Insurance Board pertaining to my request to recalculate my Earnings Basis for the above-noted claim(S). 

I also understand and agree to pay to WSIB SETTLEMENTS 10% (ten percent) of any monies received by me from the Workplace Safety & Insurance Board (WSIB) regarding my request for a recalculation of my Earnings Basis pursuant to the Workers' Compensation Act (WCA), for the above-noted claim (S), including all arrears and interest payments resulting from said recalculation request.

I also understand and agree that said payment shall be made by Bank Draft payable to WSIB SETTLEMENTS immediately following receipt by me of said payment and shall be calculated based upon any payments and/or monies owed by me to any other third party. 

Please be advised that we will not proceed with your request until all of the required information, as noted above, is provided and you have signed the appropriate sections.