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!

QuestionAnswer
Form NameWsib 1009A Form
Form Length2 pages
Fillable?No
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.

Original

Reconciliation Form

Due Date

Issue Date

Page

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.

PLEASE TYPE OR PRINT IN BLACK INK.

Section A - Calculating Total Insurable Earnings

 

Gross Earnings Before Deductions

 

1

Total Earnings per T4 Summary

 

2

Other Earnings not on T4 Summary

 

 

Contractors’ Earnings

 

3

 

 

Volunteer Forces (complete enclosed Schedule)

 

4

 

 

Optional Insurance (see Attachment 1)

 

5

 

 

 

 

6

Total Gross Earnings Before Deductions

 

 

 

 

 

Deductions From Gross Earnings

 

7

Non−insurable Gross Earnings

 

 

Executive Officers’ Earnings

 

8

 

 

 

 

9

Excess Earnings

 

 

 

 

 

 

 

10

Total Deductions

 

 

 

 

11

Total Insurable Earnings (Box 6 minus box 10)

 

 

 

 

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

NOTE:

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

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

Classification

CU Code

RG

CU Description

(A) Direct Earnings

(B) Common Earnings

(C)

Insurable Earnings = (A) +( B)

1009A (10/10)

Section C - Premium Calculation

Classification

CU Code

RG

CU Description

(C)

Insurable Earnings from Section B

(D) Rate per $100

CU Premium

(C) X (D) ÷ 100

12

Total

Insurable

Earnings

(Equals box 11)

Total

 

 

 

 

Premium

 

 

 

13

Amount

 

 

 

 

 

 

 

 

 

 

(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.

16

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.

15

Amount Due

17

If box 15 is positive, enter amount here.

Amount Paid

18

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)

 

 

Title

 

Date Completed

 

 

 

 

 

 

 

Signature

 

 

Telephone

FAX

 

 

 

 

 

 

 

NOTE:

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.

1009A2

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For you to finalize this document, make certain you type in the necessary details in each and every field:

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

2. The subsequent step is usually to submit the next few blank fields: Failure to keep proper records or.

Completing section 2 of wsib 1009 form

Those who use this form often make errors while filling out Failure to keep proper records or in this part. Ensure you go over what you enter right here.

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