Forms

You can order WCB forms online and have them mailed to you, or print the forms below.

Employer injury reporting forms

• Employer’s Report of Injury or Occupational Disease form - C040 with Instructions (pdf, 205KB) Submit this form within 72 hours of being advised of the injury.
• Employer’s Report of Injury or Occupational Disease form - C040 form only (pdf,195KB)
• Physical Demands Analysis - C545 (doc, 182KB) Help to minimize your company's time-lost claims by helping to identify possible modified duties.

Modified work forms

This series of sample forms helps employers maintain communication with workers, health care providers and the WCB case manager in order to manage injuries and arrange modified work.

• Fitness for work form (pdf, 30KB)
• Offer of Modified work agreement form (pdf, 23KB)
• Notice to injured employee form (pdf, 19KB)
• Physical Demands Analysis form - C545 (pdf, 182KB)

Employer forms (A - Z)

• Claims Audit Self-Evaluator form - WCB-015 (pdf, 972KB) Learn about reporting work-related accidents, communicating with injured employees and return-to-work best practices.
• Claim Cost Transfer form - A638 (pdf, 26KB) Complete this form to initiate a cost transfer review if you believe another employer or their worker was negligent in causing injury to your worker.
• Closing a WCB-Alberta account - A635 (pdf, 38KB)
• Damaged Eyeglasses - no personal injury form - C697 (pdf, 47KB) Use this form when only eyeglasses have been damaged (an eye injury has not been sustained).
• Deeming Application (pdf, 26KB) Use this form to assume responsibility for a worker not under the Act.
• Employer’s Progressive Injury Questionnaire - C606 (pdf, 14KB) To help determine if an injury is work-related complete and submit this form.
• Employer Release of Information - A627 (pdf, 18KB) This form, once completed grants authority to a representative to access and manage claim and/or account information on your behalf.
• Employer’s Report of Injury or Occupational Disease form - C040 with Instructions
  (pdf, 221KB)
• Employer’s Report of Injury or Occupational Disease form - C040 form only (pdf,195KB) Be sure to submit this form within 72 hours of being advised of the injury.
• Fitness for work form (pdf, 30KB)
• FOIP - Request to access information (pdf, 590KB)
• FOIP - Request to correct personal information (pdf, 593KB)
• Hearing claims - Employer’s Information Questionnaire - C139 (pdf, 19KB) To help determine if hearing loss is a work-related condition.
• Individual earnings record - A321 (pdf, 15KB)
• Interjurisdictional trucking application - A596 (pdf, 24KB)
• Offer of Modified work agreement form (pdf, 23KB)
• OIS employer sign-up (pdf, 83KB)
• Partnerships in Injury Reduction (PIR) Employer Registration form (pdf, 55KB) To participate in the PIR program complete this registration form.
• Physical Demands Analysis form - C545 (pdf, 182KB) A Physical Demands Analysis (PDA) outlines all aspects of a position including job description, critical job demands, typical workday processes and environmental factors. PDAs may help to minimize your company's time-lost claims by helping to identify possible modified duties.
• Pre-authorized Debit Plan form (pdf, 39KB) We offer a Pre-authorized Debit (PAD) service for employers to pay their premiums. You can also request monthly instalments, if your annual premiums are over $1,200 when you pay your invoices using PAD. To enroll in this convenient payment method, complete this form and return it to us by mail or fax with a void cheque.
• Request for Claim File Information form - C896 (pdf, 52KB) Fill in this form online and fax to WCB-Alberta's Access to Information unit.
• Request for a Review form - G040 (pdf, 35KB) Disagree with a Customer Service decision? Complete this form for a file review.
• Translation and Interpretation Services
• Wage Loss form - C394 (pdf, 20KB) If a worker has a loss of earnings as a result of leaving work to attend a medical appointment, WCB-Alberta can reimburse the worker.
• Worker Report of Injury or Occupational Disease form only - C060 (pdf, 100KB)
• Worker Report of Injury or Occupational Disease form with instructions - C060
  (pdf, 171KB)

Other resources

• Employer publications
• Worker publications and forms
• Health Care Provider forms and guides