Employer Representative Registration

I am authorized to submit this registration on behalf of the legal entity (employer) named in this
registration. I acknowledge that the information submitted in this registration is accurate and
complete to the best of my knowledge and confirms the employer’s enrollment into the Health and
Safety Excellence program.

We authorize the Workplace Safety & Insurance Board (WSIB) to disclose to the Health and Safety
Excellence program provider all financial information required for the administration of the program.
This information would include information such as: premiums, classification, experience rating,
claims frequency, and severity.

We authorize the WSIB and the Health and Safety Excellence program provider to store the information contained within for the purposes of administering the program.