200 - 1881 Scarth Street Regina SK S4P 4L1 W3

W3 200 - 1881 Scarth Street Regina SK S4P 4L1 www.wcbsask.com Phone: 306.787.4370 Toll free: 1.800.667.7590 Fax: 306.787.4311 Toll free fax: 1.888.844.7773 Click on any field to start editing. W3WrkFrm Updated: 01/20 When writing to the WCB, please print name and claim or firm number. Worker's Progress Report WCB claim number: Section A: Worker Information Name, address, postal code Home phone: Work phone: Social Insurance Number: Provincial Health Number: WCB firm number: Rate code: To complete the form, please: 1. Type or print using ink. 2. Be accurate and provide all information requested. 3. Complete Section D if you wish direct deposit payments. 4. Ensure you date and sign Section E. 5. Attach additional information, if relevant. 6. Mail OR fax report to the WCB. 7. Contact the WCB if you have any questions. Section B: Complete if you have returned to work Section C: Complete if you have NOT returned to work 1. When did you return to work? Date returned: MM/DD/YYYY Time: a.m. p.m. 2. Did you return to the employer shown in Section B on the W1? Yes No, new employer information: Firm name: Business phone number: 3. Are you doing the same job as before the injury? Yes No, explain: 4. Are you being paid the same amount as you were before your injury? Yes No, explain: 5. Did you work between the day of injury and the day you returned to work? No Yes, give dates: From: MM/DD/YYYY Time: a.m. p.m. To: MM/DD/YYYY Time: a.m. p.m. 1. Have you discussed a return-to-work plan with your employer? No Yes 2. When do you expect to return to work? Date: MM/DD/YYYY Time: a.m. p.m. If you cannot provide this information, explain reason: 3. Who is providing medical treatment? Name: Last appointment: MM/DD/YYYY Next appointment: MM/DD/YYYY Name: Last appointment: MM/DD/YYYY Next appointment: MM/DD/YYYY 4. Have you worked between the day of injury and date of this report? No Yes, give dates: Full Modified From: MM/DD/YYYY Time: a.m. p.m. To: MM/DD/YYYY Time: a.m. p.m. 5. Are you presently receiving disability benefits from the Canada Pension Plan Disability Program? If yes, please provide copy of initial acceptance letter. No Yes $ /month Effective date: MM/DD/YYYY Section D: Direct Deposit Information If you have already submitted your direct deposit information and there are no changes, do not complete this section. If you wish to have your compensation payments made directly to your bank account, please choose one of the following options: • Please attach a void cheque to this form (see example beside) and fax directly to the WCB at 1.888.844.7773, or mail to the WCB; OR • Have someone from your financial institute complete, sign and stamp a direct deposit request form and fax directly to Finance or mail it to the WCB If you need assistance, call 1.800.667.7590. Please note: If you change or close your bank account, let the WCB know in writing to avoid any delay in payment. Section E: Declaration I declare all the information provided is true and correct. I understand that criminal prosecution may result from any attempt to (1) obtain compensation benefits by fraudulent means, and/or (2) prevent collection of compensation benefits. Signature Name (please print) Date Please print & sign form before mailing/faxing. MM/DD/YYYY

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Transcript of 200 - 1881 Scarth Street Regina SK S4P 4L1 W3

Page 1: 200 - 1881 Scarth Street Regina SK S4P 4L1 W3

W3200 - 1881 Scarth Street Regina SK S4P 4L1 www.wcbsask.com

Phone: 306.787.4370 Toll free: 1.800.667.7590 Fax: 306.787.4311 Toll free fax: 1.888.844.7773Click on any field to start editing.

W3WrkFrmUpdated: 01/20 When writing to the WCB, please print name and claim or firm number.

Worker's Progress Report WCB claim number:Section A: Worker Information

Name, address, postal code

Home phone: Work phone:Social Insurance Number:Provincial Health Number:

WCB firm number: Rate code:

To complete the form, please: 1. Type or print using ink. 2. Be accurate and provide all information requested. 3. Complete Section D if you wish direct deposit payments. 4. Ensure you date and sign Section E. 5. Attach additional information, if relevant. 6. Mail OR fax report to the WCB. 7. Contact the WCB if you have any questions.

Section B: Complete if you have returned to work Section C: Complete if you have NOT returned to work1. When did you return to work?

Date returned:MM/DD/YYYY

Time: a.m. p.m.

2. Did you return to the employer shown in Section B on the W1?Yes No, new employer information:

Firm name:Business phone number:

3. Are you doing the same job as before the injury? Yes No, explain:

4. Are you being paid the same amount as you were before your injury? Yes No, explain:

5. Did you work between the day of injury and the day you returned to work?

No Yes, give dates: From:

MM/DD/YYYYTime: a.m. p.m.

To:MM/DD/YYYY

Time: a.m. p.m.

1. Have you discussed a return-to-work plan with your employer?No Yes

2. When do you expect to return to work?Date:

MM/DD/YYYYTime: a.m. p.m.

If you cannot provide this information, explain reason:

3. Who is providing medical treatment?Name: Last appointment:

MM/DD/YYYYNext appointment:

MM/DD/YYYY

Name: Last appointment:

MM/DD/YYYYNext appointment:

MM/DD/YYYY4. Have you worked between the day of injury and date of this report?

No Yes, give dates: Full Modified From:

MM/DD/YYYYTime: a.m. p.m.

To:MM/DD/YYYY

Time: a.m. p.m.

5. Are you presently receiving disability benefits from the Canada Pension Plan Disability Program? If yes, please provide copy of initial acceptance letter.

No Yes $ /month Effective date:MM/DD/YYYY

Section D: Direct Deposit Information If you have already submitted your direct deposit information and there are no changes, do not complete this section. If you wish to have your compensation payments made directly to your bank account, please choose one of the following options: • Please attach a void cheque to this form (see

example beside) and fax directly to the WCB at 1.888.844.7773, or mail to the WCB; OR

• Have someone from your financial institute complete, sign and stamp a direct deposit request form and fax directly to Finance or mail it to the WCB

If you need assistance, call 1.800.667.7590.

Please note: If you change or close your bank account, let the WCB know in writing to avoid any delay in payment.Section E: Declaration I declare all the information provided is true and correct. I understand that criminal prosecution may result from any attempt to (1) obtain compensation benefits by fraudulent means, and/or (2) prevent collection of compensation benefits.

SignatureName (please print)DatePlease print & sign form before mailing/faxing.

MM/DD/YYYY