Complaint Form - Fair Practices Commission

Are you an

Injured Worker
Employer
Service Provider

Claim #*

Firm # / Account #

Provider #

Name

First Last

Company Name

Email*

Phone*

What’s the best time of day to reach you?

Address

Street Address Address Line 2 City Province Postal Code

May we speak to WSIB staff about your concerns?

Yes
No

If represented, what is your representative's information?

Name

First Last

Company Name

Address

Street Address Address Line 2 City Postal Code

Phone

Fax

May we speak to your representative ?

Yes
No

Why do you believe you have been treated unfairly? How recent is the problem?

What outcome or result are you hoping for?

What steps have you taken to try to resolve the issue?

Is this issue under active appeal?

Yes
No

What is the decision date?

Print Form

Do you give the Fair Practices Commission permission to send you emails that could contain confidential information and confirm you understand and accept the potential risks of electronic communication? For example, emails could be misdirected, intercepted, altered or forwarded without detection to an unintended recipient.

Yes
No

Would you like a copy of your submission emailed to you?

Yes

The Commission has the authority under the Freedom of Information and Protection of Privacy Act, and the Workplace Safety and Insurance Act, to collect, use and disclose personal information while fulfilling its mandate to review and investigate alleged unfair practices by the WSIB. As part of our review we may access and review WSIB claim file information. With your consent, we may contact the WSIB about your complaint. If you have any further questions, please call the Commission at 1-866-258-4383.

Comments

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