Forms

Type
Keywords
Sort By

Your search returned 57 results. Page 1 of 6

  • Travel Expense Form
    Type: Workers
    Date: March 20, 2016 Last Revised: February 7, 2025
    Description:

    Medical expense related travel is any visit to a medical professional such as visits to physicians, physiotherapists, chiropractors and any other treatment provided to help you recover from your workplace injury.

    Non-medical expense related travel may include appointments with WorkSafeNB staff, at the staff members’ request, appointments for vocational testing or training and WCAT hearings.

  • Long-term Disability Questionnaire
    Type: Workers
    Date: March 10, 2020 Last Revised: February 5, 2025
    Description:

    In accordance with the Workers' Compensation Act, adjustments to Long-Term Disability (LTD) benefits are made on the anniversary month of your injury or recurrence of injury.

  • Employer Report of Injury or Illness
    Type: Employers
    Date: August 6, 2020 Last Revised: February 5, 2025
    Description:

    Complete this form if an employee experiences a work-related injury or illness. You must submit this to WorkSafeNB within three days of the: date of the accident if the injury or illness may entitle the worker and/or their dependent(s) to wage  replacement or medical treatment under New Brunswick’s Workers’ Compensation Act; date the employee is diagnosed with an occupational disease; or date you are notified of the accident/injury or illness by the employee.

  • Application for Workers' Compensation Benefits
    Type: Workers
    Date: August 6, 2020 Last Revised: February 5, 2025
    Description:

    Submit this form when applying for WorkSafeNB benefits, such as lost wages and/or medical treatment (physiotherapy, medication, etc.), due to a workplace injury or illness. You must complete this form and send it to WorkSafeNB within one year from the date of the accident/injury or illness.

  • Employer Report of Occupational Hearing Loss
    Type: Employers
    Date: November 2, 2020 Last Revised: February 5, 2025
  • Application for Benefits Occupational Hearing Loss
    Type: Workers
    Date: November 2, 2020 Last Revised: February 5, 2025
  • Caregiver Receipt
    Type: Workers
    Date: January 10, 2022 Last Revised: February 5, 2025
    Description:

    Use this receipt template for recording informal home care services performed for a worker (the client) receiving WorkSafeNB benefits.

  • Caregiver Disclosure Statement
    Type: Workers
    Date: January 10, 2022 Last Revised: February 5, 2025
    Description:

    Complete this disclosure statement if you plan to perform informal home care services for a worker (the client) receiving WorkSafeNB benefits.

  • Medical Aid Request
    Type: Workers
    Date: November 1, 2022 Last Revised: February 5, 2025
    Description:

    Use this form if you had an approved claim that is now closed (you're no longer receiving any benefits from WorkSafeNB such as loss of earnings or medical aid) and require medical aid for your previously approved work-related (compensable) injury or illness. 

  • Ketamine/Esketamine Review
    Type: Health Care
    Date: August 16, 2024 Last Revised: January 7, 2025

Page 1 of 6

E-News Sign-up