STEP 1 - DETERMINE ELIGIBILITY FORM

STEP 1 - DETERMINE ELIGIBILITY FORM
Please complete and submit this form to allow us to determine if your case meets our eligibility screening. If so, you will be advised to proceed to the next step.
Name

First NameLast Name
E-mail
example@example.com
Claim Number
Please select those that apply to you
Did your earnings at the time of your injury include any of the following?*

Regular OvertimePieceworkRegular Bonusses (if paid daily, weekly or monthly)Shift PremiumRetroactive Pay Increases (effective on or before the day of accident)TipsRoom & Board (if supplied as a condition of employment)Earnings in other currencies
If you responded yes to any of the above, please contact the Canada Revenue Agency (CRA) and request copies of your T4 Slips and Option C Forms for the year of your injury or occupational disease and the year before.
Should be Empty: