Wsib 1009A Form PDF Details

If you are a worker in the province of Ontario, Canada, and have been injured on the job, you will need to fill out and submit a Wsib 1009A form to the Workplace Safety and Insurance Board (WSIB). This form is used to report an injury or illness that has occurred at work, and to seek benefits from WSIB. In this blog post, we will go over what information is required on the Wsib 1009A form, and provide tips on how to complete it accurately and efficiently. Let's get started!

Form NameWsib 1009A Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameswsib 1009a form, wsib for 1009a, 1009a printable fillable, wsib reconciliation 2019 form

Form Preview Example

P.O. Box 4115

Station A

Toronto ON M5W 2V3

All information is strictly confidential.


Reconciliation Form

Due Date

Issue Date


Account No.

Firm No.

Reconciliation Period Covered

Telephone Enquiry Number

(416) 344-1000 1-800-387-00

WSIB Interest Rate

Annual −

For information on how to complete this form refer to the Reconciliation Guide.


Section A - Calculating Total Insurable Earnings


Gross Earnings Before Deductions



Total Earnings per T4 Summary



Other Earnings not on T4 Summary



Contractors’ Earnings





Volunteer Forces (complete enclosed Schedule)





Optional Insurance (see Attachment 1)








Total Gross Earnings Before Deductions






Deductions From Gross Earnings



Non−insurable Gross Earnings



Executive Officers’ Earnings








Excess Earnings









Total Deductions






Total Insurable Earnings (Box 6 minus box 10)





Section B - Allocation of Total Insurable Earnings by Classification You must complete Section B


Do not write over any preprinted information. Only the original should be completed and returned in the envelope provided.




If your business differs from the classification(s) below, notify your WSIB account representative.


CU Code


CU Description

(A) Direct Earnings

(B) Common Earnings


Insurable Earnings = (A) +( B)

1009A (10/10)

Section C - Premium Calculation


CU Code


CU Description


Insurable Earnings from Section B

(D) Rate per $100

CU Premium

(C) X (D) ÷ 100





(Equals box 11)






















(If less than $100, enter $100)

Total Premium Amount Reported

(The sum of the premiums previously14 reported for this reconciliation period.)

Does the amount in Box 14 match your records?

• If not the reason may be that our records do not show your most recent reporting period. The amount recorded is the total premiums reported throughout the year, not premiums actually paid.


Section D - Certification:

Reconciled Difference (Box 13 minus box 14)

Credit to Account

If box 15 is negative, enter amount here.

Please enclose payment with this form. Payment cannot be accepted at any financial institution.


Amount Due


If box 15 is positive, enter amount here.

Amount Paid


I hereby certify that I am an owner (or authorized officer) responsible for this account and that, to the best of my knowledge, the information on this form and on any documents attached is true and correct.

Account No.


Company Legal Name











Name (please print)





Date Completed





















If this form is not received by the due date, the WSIB will calculate a premium for the reconciliation period and charge 1% of that amount (to a maximum of $1000) for each month the form is not received.

Employers are required to keep accurate records of all earnings and deductions declared on this form. The WSIB must be able to verify the earnings and deductions declared from the employer's records.

Failure to keep proper records, or submitting an inaccurate form, can result in penalty or prosecution.


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1. It's essential to complete the wsib annual reconciliation form properly, hence be attentive when working with the sections comprising these blanks:

Guidelines on how to fill out wsib 1009 form part 1

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Completing section 2 of wsib 1009 form

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