Determining worker/independent operator status
General questionnaire
Mail to: 200 Front Street West, Toronto ON M5V 3J1 | Email to: [email protected]
Complete the general – determining worker/independent operator status questionnaire if the following applies:
• you are not employing full or part-time help, and
• you have been asked to show proof of WSIB coverage by the company or companies with which you currently
have a contract, or
• you are a company engaging contractors and need a worker/independent operator status determination, or
• you would like to establish an account for optional insurance
What do I need to submit to the WSIB?
Please submit a completed version of this questionnaire signed by you and the company with whom you currently have
a contract. When completing the questionnaire, you are considered the individual and the company with whom you
have a contract is considered the principal.
Individuals who have been determined to be independent operators by the WSIB can apply for optional insurance. If you
are requesting optional insurance, please include a completed optional insurance request/change form (enclosed) along
with proof of earnings. Optional insurance becomes effective on the date we receive the signed request for optional
insurance.
Please send your completed questionnaire to [email protected] or by mail to 200 Front Street West,
Toronto, ON M5V 3J1.
Please call 1-800-387-0750 if you need more information or help.
Contact [email protected] if you require this communication in an alternative format.
Ce document est disponible en franҫais sous le titre : Détermination du statut de travailleuse/travailleur ou
d’exploitante indépendante/exploitant indépendant Questionnaire général, 1158B (06/23)
wsib.ca | Mail: 200 Front Street West, Toronto, Ontario, M5V 3J1 | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050 | Fax: 1-888-313-7373
1158A (06/23) Page 1 of 5
Determining worker/independent operator status
General questionnaire
Mail to: 200 Front Street West, Toronto ON M5V 3J1 | Email to:
[email protected] Who should complete this questionnaire?
• individuals who believe they may be independent operators
• the hiring company or their respective representatives
The individual and the company may submit separate questionnaires if:
• they disagree with the answers to some or all of the questions
• the individual wants to submit the financial information required to support the answers in part 3 to the
WSIB in confidence
We will review your response and notify both the individual and company of our decision in writing.
Key terms
Workers are entitled to benefits provided by the Workplace Safety and Insurance Act and their employers must pay
premiums to the WSIB.
Independent operators can choose to apply for coverage as workers under the Workplace Safety and Insurance Act. If
they want insurance, they must pay their own premiums.
Company is the principal or the business that hires the individual.
List two to four companies that you (the individual) have entered into a contract for service or business relationship with
in the last 18 months:
Name of company Phone number
Part 1
What type of legal entity does the individual operate?
Sole proprietorship Partnership Corporation Other
What is the legal name?
What service does the individual provide for the company?
What is the company’s main business?
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Part 1 (continued)
Is there a written contract stating the terms of the work relationship? Yes No
If yes, please include a copy of the contract.
Does the individual have a previous or current WSIB account number? Yes No
If yes, please provide this number.
Part 2
Training and supervisions
Does an employee of the company train and/or supervise the individual? Yes No
Does the individual have to attend meetings and follow specific instructions that indicate the
company wants the services performed in a particular way? Yes No
Hours of work
Does the company set the hours and days of work? Yes No
Does the individual decide their vacation time? Yes No
Order or sequence of work
Does the individual perform services in the order or sequence set by the company? Yes No
Does the individual report to the company’s office at specified times, follow up on leads and Yes No
perform tasks at set times?
Is the individual’s work coordinated with the work of others employed by the company? Yes No
Manner of payment
Does the company pay the individual in regular amounts at stated intervals? Yes No
Does the company decide the amount and manner of payment? Yes No
Does the individual receive payment for overtime or statutory holidays? Yes No
Does the individual receive a T4 income tax slip from the company? Yes No
Does the company pay the individual according to a standard pay or rate scale? Yes No
Licences
Does the company hold the licences (if required) to do the work? Yes No
Serving the public
Does the individual make their services available on behalf of or as a representative of the Yes No
company?
Does the individual invoice customers on the company’s behalf? Yes No
Does the individual file HST returns? Yes No
Does the individual invoice the company for materials used to complete the work? Yes No
Does the individual wear a uniform that has the company’s name, colours or logo on it? Yes No
Please provide the individual’s website address
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Part 2 (continued)
Is the individual registered as a business with the Ministry of Public and Business Service Yes No
Delivery?
Collective agreement
Do the terms of a collective or union agreement govern the relationship? Yes No
Part 3
What assets (including labour, materials, tools and equipment) are required to do this work?
Beside each of the assets listed, please state the approximate value of each item or its cost in dollars per month.
Does the individual own 80 per cent or more of the equipment (i.e., business vehicle, tools, Yes No
computer, etc.) necessary to do the work?
What costs are incurred in doing the work? This includes the costs of the acquisition, maintenance, operation and repair
of assets, as well as financing and loan arrangements with respect to the work and licensing and insurance fees.
Does the individual pay for these expenses? Yes No
Part 4
Hiring, supervising and paying assistants
Does the individual hire, supervise and pay workers at the company’s direction (i.e., act as a
supervisor or representative of the company)? Yes No
If helpers are needed:
Can the company hire, discipline or fire these helpers? Yes No
Does the individual pay the helpers directly? Yes No
Doing work on company premises
Does the company own or control the site where the work is performed? Yes No
Oral and written reports
Does the individual have to submit regular oral or written reports to the company? Yes No
Right to terminate
Can the individual end their relationship with the company at any time? Yes No
If the individual’s work is unsatisfactory, who has to correct it?
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Part 4 (continued)
If additional work has to be done to correct or improve a job, does the individual have to accept
Yes No
these costs or any other losses due to poor workmanship?
Working for more than one firm at a time
Is the individual engaged in work for more than one company at the same time? Yes No
Does the individual’s contract with the company prohibit the individual from working for others? Yes No
Declaration
To the best of my knowledge, information and belief, the information contained in this document is true.
I/we understand that the WSIB reserves the right to audit and verify these responses. If these responses do not truly
represent the nature of the working relationship, the WSIB may reverse the determination of status retroactively to the
date that the working relationship began.
By signing below, the individual acknowledges that if they experience a work-related injury or illness, they will not be
eligible for any WSIB benefits unless they request optional insurance coverage and the WSIB approves it.
Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act and may
be used to register/determine your status for coverage and to administer and enforce the act.
First name Last name
Signature Date (dd/mmm/yyyy)
Address
City Province Postal code Phone number
Authorizing name WSIB account
Company name Position
and signature number
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Optional insurance
request/change
Please complete this section in full except
where there is preprinted information.
Account number Firm number
Date
Requesting or changing optional insurance
To request optional insurance, please complete sections A and B.
To change the amount of existing optional insurance, please complete sections A and C.
Please also:
• provide proof of earnings (see below)
• have the applicant review and sign the optional insurance declaration (attached)
• have the owner’s certification completed and signed (attached)
Cancelling optional insurance
Individuals who are cancelling their optional coverage must complete section D or forward their request in writing to the
WSIB.
Proof of earnings
We accept the following documents (issued by the owner or authorized officer responsible for the account) as proof of
earnings.
For executive officers:
• T4s and T4As or any other document submitted to the Canada Revenue Agency (CRA) to report earnings
For sole proprietors and partners:
• audited financial statements prepared by a professionally designated accountant
• income tax returns with supportive income statements (T1, T2125, T2032, etc.) or other documents submitted to the
CRA to report business income
Please note:
• if the sole proprietor or partnership has been in business for less than one year, the amount of coverage for premium
benefit purposes is set at one-third of the annual maximum insurable earnings
• if the executive officer’s company has been in business for less than one year, the amount of coverage for premium
and benefit purposes is set at one-third of the annual maximum insurable earnings or the amount stated on the
optional insurance form
• if the applicant’s company has been in business for more than one year, the amount of coverage for premium and
benefit purposes must accurately reflect the applicant’s actual annual earnings, as supported by the documents
listed above
• coverage will not be provided if your operation shows a net business loss
Contact [email protected] if you require this communication in an alternative format.
Ce document est disponible en franҫais sous le titre : Demande ou modification d’assurance facultative, 1574B (06/23)
wsib.ca | Mail: 200 Front Street West, Toronto, Ontario, M5V 3J1 | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050
1574A (06/23) Page 1 of 4
wsib.ca
• loss of earnings benefits are not paid if your operation shows a net business loss despite active optional insurance
• the WSIB may deny the request (or coverage renewal) for optional insurance if the applicant can’t substantiate their
level of earnings
Any new requests for optional insurance or changes to the amount of optional insurance will take effect on the date we receive
the signed request and satisfactory proof of earnings. We require pre-payment for optional insurance premiums.
The amount of optional insurance will not be retroactively adjusted if the applicant receives benefits at an amount that is lower
than the amount of optional insurance.
Please call us at 1-800-387-0750 if you have any questions or require more information.
This form continues on the following page.
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Section A
First name Middle name Last name
Date of birth (dd/mmm/yyyy) Title/position with company
Home address (This address must be a physical address, not a box number or general delivery) City
Province Postal code Phone number Date business commenced (dd/mmm/yyyy)
Section B - Complete if requesting new optional insurance
Amount of coverage requested Today’s date (dd/mmm/yyyy)
Section C - Complete if requesting a change in the amount of existing optional insurance
Revised coverage amount requested Today’s date (dd/mmm/yyyy)
Section D - Complete if cancelling existing optional insurance
Name Today’s date (dd/mmm/yyyy)
Optional insurance declaration
Please read the following information carefully. It explains how optional insurance changes your status under the
Workplace Safety and Insurance Act (the Act).
I understand that:
1. O
wners, partners, executive officers and independent operators are not automatically entitled to benefits under the
Act, unless they are included in expanded compulsory coverage in construction.
2. I am voluntarily requesting to be considered a worker by the WSIB by applying for optional insurance as I am exempt
from WSIB mandatory coverage.
3. I must have optional insurance for a minimum of three consecutive months.
4. With optional insurance, I am entitled to all benefits workers receive.
5. I am giving up my right to sue workers and businesses whose industries are covered under Schedule 1 of the Act for
damages sustained in a workplace injury.
6. I must send the WSIB proof of earnings when first requesting optional insurance.
7. If my earnings level changes, I must send the WSIB a signed request to revise the amount of insurance coverage,
along with proof of earnings.
8. The WSIB may deny my request for coverage if I do not provide proof of earnings.
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9. The WSIB may request proof of earnings at any time.
10. The WSIB may adjust the amount of optional insurance that I request.
11. My optional insurance will continue beyond the minimum three months until either the WSIB or I cancel the insurance.
12. If I have a workplace injury, my optional insurance will remain in effect until I notify the WSIB, in writing, that I wish to
cancel it or that my status has changed to mandatorily covered.
13. If I have a workplace injury, my earnings at the time of my injury will be compared to the amount of my optional insurance.
The WSIB will base benefits on whichever is the lower amount - my earnings or my optional insurance coverage.
14. If I am paid benefits at an amount that is lower than the amount of my optional insurance, the amount of my optional
insurance will not be retroactively adjusted.
15. T
he WSIB may cancel or deny renewal of my optional insurance if the business paying for it has amounts owing, or
the WSIB determines I am mandatorily covered under the Act. If any premium is owing on my optional insurance, the
amount of the unpaid premium may be deducted from my benefits.
16. T
he effective date for new optional insurance requests, changes to or cancellations of optional insurance will either be
the date that the completed optional insurance request/change form is received by the WSIB, or the requested date,
whichever is later.
17. If the WSIB determines I am mandatorily covered, the effective date of changes to, or cancellation of, my optional
insurance may be made retroactively.
Applicant’s name Applicant’s signature Date (dd/mmm/yyyy)
Owner’s certification
I hereby certify that I am an owner (or authorized officer) responsible for this account. I also certify that the amount
of optional insurance requested accurately represents the earnings of the applicant.
I acknowledge that the accident costs associated with any work-related injuries for the applicant will be applied to
the accident record for this account.
Personal information on this form is collected under the authority of the Act, and may be used to register/determine
your status for coverage and to administer and enforce the Act. If you have any questions, please call 1-800-387-0750.
Name of owner or authorized officer Title
Signature Phone number Date completed (dd/mmm/yyyy)
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