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WORKERS' COMPENSATION CLAIM LETTER
Prepared October 23, 2026 · Ontario, Canada
RECITALS
WHEREAS the undersigned desires to set out in writing the matters described below;
WHEREAS this document has been prepared with reference to the laws of Ontario, Canada;
NOW, THEREFORE, the following provisions shall apply:
Jordan Miller
123 Example Street, Toronto, ON M4B 1B3
(416) 555-0142
October 23, 2026
To: Workplace Safety and Insurance Board (WSIB)
Claims Department
Re: Workers' Compensation Claim
Claimant: Jordan Miller
Date of injury: 2026-09-14
Filing deadline: March 14, 2027 — 142 days remaining (confirm with the Workplace Safety and Insurance Board (WSIB))
Employer: Example Logistics Inc.
Employer address: 88 Industrial Road, Mississauga, ON L5T 1N7
Board file number: Example file #2026-1042
Dear Claims Officer,
I am writing to formally file a workers' compensation claim for a workplace injury I sustained on 2026-09-14 while employed by Example Logistics Inc..
WHAT HAPPENED
While unloading a delivery truck, I lifted a box weighing approximately 28 kg from the trailer floor and felt a sharp pain in my lower back. I reported it to my shift supervisor the same day and visited a walk-in clinic that evening.
BODY PART INJURED
Lower back (lumbar strain)
I reported this injury to my employer and sought medical attention promptly. I am requesting that my claim be accepted and that I receive the benefits I am entitled to under the workers' compensation legislation of Ontario, including wage-loss benefits and coverage of related medical treatment.
Supporting documents provided with this claim:
Clinic visit note dated September 14, 2026
Supervisor's incident report
Photograph of the delivery area
Please confirm receipt of this claim in writing and advise me of my claim number and the name of the adjudicator assigned to my file.
I trust this information is sufficient for you to begin processing my claim. I can be reached at the address and phone number above.
Yours faithfully,
Jordan Miller
(416) 555-0142
NEXT STEPS CHECKLIST
1. Tell your doctor or hospital that this was a work injury so it is recorded as such.
2. Report the injury to your employer in writing as soon as possible and keep a copy.
3. File your claim with the Workplace Safety and Insurance Board (WSIB) — most claims can be filed online or by phone.
4. Keep copies of every medical note, receipt, letter, and email about your injury.
5. Write down your claim/file number as soon as it is assigned and use it on all correspondence.
6. Follow your treatment plan and attend all medical appointments.
7. If your claim is denied or closed, you have the right to appeal — check the Workplace Safety and Insurance Board (WSIB) appeal deadlines carefully, as they are strict.
8. Consider speaking with a workers' compensation advocate or a lawyer in Ontario if you need help.
IMPORTANT: This is a template, not legal advice. Review it with a licensed lawyer or advocate in Ontario before submitting.
IN WITNESS WHEREOF, the undersigned has duly executed this document as of the date first written above.
Executed by:
Signature: ___________________________ Date: _______________
Printed name:
WITNESS
Signature: ___________________________ Date: _______________
Printed name:
This document is a self-help template and does not constitute legal advice. Independent legal advice from a licensed lawyer in Ontario is recommended before reliance.
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