Clone of All-In-One Membership Two-Payment Option

All-In-One Membership Registration
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Your E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Accident*

DayMonthYear
Date
Date of Birth*

DayMonthYear
Date
WSIB Claim Number*
Membership Payment Options
Please select the payment amount that works for you.*

$380 Monthly (3 months)$200 Monthly (6 months)$150 Monthly (12 months
Select from below your payment method
Payment by e-transferPayment by Credit/Debit Card
If you selected Payment by e-transfer, use the email address payments@wsibsettlements.com

If you selected Payment by Credit/Debit Card, you will receive an invoice and a payment schedule at which time you can make your first payment.
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All-In-One Membership Registration