ACSESS WSIB HSEP Registration

Contact Information

Company Name: *

WSIB Account Number: *

Primary Contact for this Company

First Name: *

Last Name: *

Address: *

Suite:

City: *

Province: *

Postal Code/Zip Code: *

Phone: (Please include area code) *

Email: *

*Premium information can be accessed through the account controller by logging into their services to view your balance, account activities, and statements.

Premium Ranges	Member Rate	Non-Member Rate
$1 - $100,000	$1,200.00	$1,500.00
$100,001 - $1,000,000	$1,500.00	$1,800.00
$1,000,001 - $5,000,000+	$3,000.00	$3,500.00

Are you an ACSESS Member? *

Select your Premium Range *

$1 - $100,000
$100,001 - $1,000,000
$1,000,001 - $5,000,000+

What is the average number of full time and placement workers under this WSIB account number: *

Authorization *

Yes, I am authorized on behalf of my company to apply to participate in the ACSESS WSIB Health and Safety Excellence program for 2020 in accordance to the requirement of this agreement.

ACSESS WSIB HSEP TERMS OF SERVICE AGREEMENT *

I have read and agree to the Terms of Service.