Free fillable Employer's Report Of Injury Disease Form 7 (WSIB) PDF form (2023)

AB

Did you know that you can

securely file your

Form 7 online?

Our online 'eForm 7' offers a fast, effective solution

for managing your Form 7 reports with the WSIB.

New features in our eForm 7 make reporting

online even quicker and easier.

To submit an eForm 7, visit our eWSIB online services

page. It only takes a few minutes to subscribe and you

can start filing your reports right away.

Please note: If you're submitting a No Lost Time

claim, only complete sections A to D, E (#1) and J.

Mail To:

200 Front Street West

Toronto ON M5V 3J1

OR Fax To:

416-344-4684

OR 1-888-313-7373

Toll free: 1-800-387-0750

TTY: 1-800-387-0050

wsib.ca

Employer's Report

of Injury/Disease (Form 7)

Claim Number

7

Please PRINT in black ink

A. Worker Information

Job Title/Occupation (at the time of accident/illness - do not use abbreviations)

Length of time in this position

while working for you

Social Insurance Number

Please check if this worker is a: spouse or relative of the employer

executive

elected official owner

Is the worker covered by a

Union/Collective Agreement?

Worker Reference Number

Last Name First Name

yes no

Worker's preferred language

dd mm yy

Date of

Birth

Address (number, street, apt., suite, unit)

English

French

Other

Telephone

Province

City/Town Postal Code

dd mm yy

Sex

Date of

Hire

F

M

Fold here for

#10 envelope

B. Employer Information

?

Trade and Legal Name (if different provide both)

Check

one:

Provide Number

Firm

Number

Account

Number

OR

Class/Subclass NAICS Code

Mailing Address

Telephone

City/Town Postal Code

Province

FAX Number

Description of Business Activity

Does your firm have 20 or

more workers?

yes

no

Branch Address where worker is based (if different from mailing address - no abbreviations)

City/Town Province Alternate Telephone

Postal Code

C. Accident/Illness Dates and Details

dd mm yy

1. Date and hour of

accident/Awareness

of illness

2. Who was the accident/illness reported to? (Name & Position)

AM

PM

dd mm yy

Telephone Ext.

Date and hour reported

to employer

AM

PM

3. Was the accident/illness:

4. Type of accident/illness: (Please check all that apply)

Sudden Specific Event/Occurrence Fall Slip/Trip

Struck/Caught

Gradually Occurring Over Time

Overexertion

Harmful Substances/Environmental

Motor Vehicle Incident

Occupational Disease

Repetition Assault

Fatality

Fire/Explosion

Other

5. Area of Injury (Body Part) - (Please check all that apply)

Right Right

Left Right Right

Left Left Left

Upper back

Head Teeth

Face Lower back

Neck Shoulder Wrist

Hip Ankle

Hand

Arm

Foot

Thigh

Eye(s) Chest Abdomen

Elbow Finger(s)

Ear(s) Pelvis

Toe(s)

Knee

Forearm

Lower Leg

Other

6. Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb. box, slipped on wet floor, repetitive movements,

etc. . .). Include what the injury is and any details of equipment, materials, environmental conditions (work area, temperature, noise, chemical, gas, fumes, other

person) that may have contributed. For a condition that occurred gradually over time, please attach a description of the physical

activity required to do the work.

If you are having difficulty accessing or completing this document, please contact : accessibility@wsib.on.ca

Page 1 of 4

0007A (01/20)

A guide to complete this form is available at wsib.ca

Employer's Report

wsib.ca

of Injury or Illness (Form 7)

Claim Number

7

Please PRINT in black ink

Social Insurance Number

Worker Name

C. Accident/Illness Dates and Details (Continued)

Specify where (shop floor, warehouse, client/customer site, parking lot, etc..).

7. Did the accident/illness happen on the employer's

premises (owned, leased or maintained)?

yes no

If yes, where (city, province/state, country).

8. Did the accident/illness happen outside the Province

of Ontario?

yes no

If yes, provide name(s), position(s), and work phone number(s).

9. Are you aware of any witnesses or other employees

involved in this accident/illness?

1.

yes no

2.

If yes, please provide name and work phone number

10. Was any individual, who does not work for your firm,

partially or totally responsible for this

accident/illness?

yes no

If yes, please explain

11. Are you aware of any prior similar or related problem,

injury or condition?

yes no

12. If you have concerns about this claim, attach a written submission to this form.

submission attached

D. Health Care

dd yy dd yy

mm mm

2. When did the employer learn that the worker

received health care?

1. Did the worker receive health care for this injury?

yes no If yes, when :

3. Where was the worker treated for this injury? (Please check all that apply)

On-site health care Ambulance Emergency department Admitted to hospital Health professional office Clinic

Other:

Name, address and phone number of health professional or facility who treated this worker (if known).

E. Lost Time - No Lost Time

1. Please choose one of the following indicators. After the day of accident/awareness of illness, this worker:

Returned to his/her regular job and has not lost any time and/or earnings. (Complete sections G and J).

Returned to modified work and has not lost any time and/or earnings. (Complete sections F, G, and J).

Has lost time and/or earnings. (Complete ALL remaining sections).

dd yy dd yy

mm mm

regular work

Provide date worker first lost time Date worker returned to work (if known)

υ

υ

modified work

2. This Lost Time - No Lost Time - Modified Work information was confirmed by:

Telephone Ext.

Myself

Other

Name

F. Return To Work

2. Has modified work been

discussed with this worker?

3. Has modified work been

offered to this worker?

If yes, was it

1. Have you been provided with work

limitations for this worker's injury?

Accepted

Declined

If Declined please attach a copy of

the written offer given to the worker.

yes no yes no yes no

4. Who is responsible for arranging worker's return to work

Telephone Ext.

Other

Myself

Name

Page 2 of 4

0007A (01/20)

Employer's Report

of Injury/Disease (Form 7)wsib.ca

Claim Number

7

Please PRINT in black ink

Worker Name Social Insurance Number

G. Base Wage/Employment Information - (Do not include overtime here)

1. Is this worker (Please check all that apply)

Owner Operator or

(Sub) Contractor

Casual/Irregular Registered Apprentice

Permanent Full Time Student

Permanent Part Time

Seasonal

Unpaid/Trainee Optional Insurance

Temporary Full Time

Contract

Other

Temporary Part Time

2. Regular rate of pay

$

per hour day week other

H. Additional Wage Information

Provide

percentage

1. Net Claim Code

or Amount

2. Vacation pay

- on each cheque?

%

Federal Provincial

yes no

3. Date and hour last worked 4. Normal working hours on

last day worked

5. Actual earnings for

last day worked

6. Normal earnings for

last day worked

dd mm yy

From

To

AM

AM AM

$

$

PM

PM PM

7. Advances on wages:

Is the worker being paid while he/she recovers?

yes no Full/Regular Other

If yes, indicate:

8. Other Earnings (Not Regular Wages): Provide the total of additional earnings for each week for the 4 weeks before the accident/illness.

* For Rotational Shift workers - If the shift cycle exceeds 4 weeks,

please attach the earnings information for the last complete shift

cycle prior to the date of accident/illness.

Use these spaces for any other earnings

(indicate Commission, Differentials, Premiums,

Bonus, Tips, In Lieu %, etc..).

θ

Mandatory

Overtime Pay

Voluntary

Overtime Pay

From Date

(dd/mm/yy)

To Date

(dd/mm/yy)

Period

$ $ $ $ $ $

Week 1

Week 2

$ $ $ $ $ $

$ $ $ $ $ $

Week 3

Week 4 $ $ $ $ $ $

I. Work Schedule (Complete either A, B or C. Do not include overtime shifts)

Example: Monday to Friday, 40 hours

(A.) Regular Schedule - Indicate normal work days and hours.

υ

S M T W T F S

Sunday

Monday Tuesday Wednesday Thursday Friday Saturday

8 8 8 8 8

or,

(B.) Repeating Rotational Shift Worker - Provide

NUMBER OF

DAYS ON

NUMBER OF

DAYS OFF

HOURS

PER SHIFT(s)

NUMBER OF WEEKS

IN CYCLE

Example: 4 days on, 4 days off, 12 hours per shift, 8 weeks in cycle.

υ

or,

- Provide the total number of regular hours and shifts for each week for the 4 weeks

prior to the accident/illness. (Do not include overtime hours or shifts here).

(C.) Varied or Irregular Work Schedule

Week 3

Week 4

Week 1 Week 2

From/To Dates (dd/mm/yy)

Total Hours Worked

Total Shifts Worked

J. It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board.

I declare that all of the information provided on pages 1, 2, and 3 is true.

Name of person completing this report (please print) Official title

dd yy

mm

Signature Telephone Ext. Date

THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER

Page 3 of 4

0007A (01/20)

Employer's Report

of Injury/Disease (Form 7)wsib.ca

Claim Number

7

Please PRINT in black ink

Worker Name Social Insurance Number

K. Additional Information

THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER

0007A (01/20) Page 4 of 4