Determining worker/independent operator status

Transportation industry
Mail to: 200 Front Street West, Toronto ON M5V 3J1 | Email to: [email protected]

Complete the transportation industry — determining worker/independent operator status questionnaire if one of
the following applies:
• you are not employing full or part-time help, and
• you have been asked to show proof of WSIB coverage by the company or companies with which you
currently have a contract, or
• you are a company engaging contractors and require a worker/independent operator status determination, or
• you would like an account established for optional insurance

What do I need to submit to the WSIB?

1. A completed version of this questionnaire signed by you (the owner-operator or individual) and the company
with whom you currently have a contract (the principal)
2. A copy of the licence plate and vehicle portion of the permit (ownership)
3. If applicable, a copy of your vehicle lease or rental agreement

When completing the questionnaire, you’re considered the owner-operator or individual and the company with whom you
have a contract is considered the principal. Owner-operators or individuals who have been determined to be independent
operators by the WSIB can apply for optional insurance.

If you are requesting optional insurance, please include a completed Optional insurance request/change form (enclosed)
along with proof of earnings. Optional insurance becomes effective on the date the WSIB receives the signed request for
optional insurance.
Please send your completed questionnaire and supporting documents to us by email at [email protected]
or by mail to 200 Front St W., Toronto, ON M5V 3J1.

Please call us at 1-800-387-0750 if you need more information or help.

Important information about status decisions for the transportation industry:

• You only need to complete a questionnaire the first time a ruling is requested with a specific vehicle
identification number (VIN)
• If we determine the individual is an independent operator, we’ll provide a decision letter with the VIN
included. If the independent operator performs transportation services for another principal using the vehicle
with the VIN listed in the letter, they can provide the decision letter to that principal
• If a new vehicle/VIN is used, a new questionnaire would need to be completed and sent in with both parties’
signatures and all required supporting documentation

Contact [email protected] if you require this communication in an alternative format.

Ce document est disponible en franҫais sous le titre : Détermination du statut de travailleuse/travailleur ou
d’exploitante indépendante/exploitant indépendant Industrie du transport, 10687B (06/23)
wsib.ca | Mail: 200 Front Street West, Toronto, Ontario, M5V 3J1 | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050
10687A (06/23) Page 1 of 4
 Determining worker/independent operator status
Transportation industry
Mail to: 200 Front Street West, Toronto ON M5V 3J1 | Email to: [email protected]

Who should complete this questionnaire?

• owner-operators in the trucking industry
• individuals who drive a vehicle to courier (pick up and deliver) packages, parcels or letters*
• individuals who perform third-party delivery of food and/or products
• individuals who drive passengers to and from requested destinations via rideshare
• the principal that hired them or their authorized representatives
*Couriers who collect or deliver on foot or by bicycle are considered workers and should not complete this
questionnaire.

If you are an owner-operator in trucking, complete section A and review section B.

If you are an individual in the courier or rideshare industry, complete section A and review section C.

If the owner-operator/individual meets all the criteria listed in section B or C, both the owner-operator/individual
and the principal must sign the declaration in order to verify that the statements reflect the work relationship. Your
acknowledgement to the statements in section B or C will indicate whether you’re an independent operator or a worker
under the Workplace Safety and Insurance Act.

Please note:
• Owner-operators and individuals that are incorporated aren’t automatically assumed to be independent
operators. They must still complete this questionnaire to determine their status
• Taxi industry owner-operators are required to complete the general – determining worker/independent
operator status questionnaire
Key terms
Workers are entitled to benefits provided by the Workplace Safety and Insurance Act and their employers must pay
premiums to the WSIB.
Independent operators can choose to apply for coverage as workers under the Workplace Safety and Insurance
Act. If they want insurance, they must pay their own premiums.
Principal is the company, carrier or shipper that hires the owner-operator/individual to transport people and/or goods.

Part A – To be completed by all transportation industries

What services does the owner-operator/individual provide for the principal? (Describe the equipment)

What equipment and vehicle does the owner-operator/individual own, rent or lease that is required to haul goods or
courier packages, parcels or letters (i.e., car, van, truck, two-way radio, cell phone)?

Provide the VIN found on the owner-operator/individual’s

ownership documents.
Does the owner-operator have a previous or current WSIB account number? Yes No

If yes, please provide the account number

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Part B – Trucking industry

Owner-operators will be treated as independent operators, for workplace safety and insurance purposes only, when the
work relationship contains all of the following features:
1) The owner-operator pays for the truck and a majority of the equipment or other related property (such
as payments for gas, truck maintenance, licence and storage) and isn’t required to finance the truck and
equipment/related property through the principal company sources.
2) The owner-operator has the right to choose the vehicle and has market mobility in that they have discretion to
enter into contracts of any duration to transport goods and maximize profits.
3) The principal doesn’t have the right to control where or from whom the owner-operator purchases products/
services. However, this does not preclude the owner-operator from exercising their option to purchase products/
services from the principal.
4) The principal doesn’t have the right to exercise control over the owner-operator’s operations except:
• to the extent that loads are offered and destinations and delivery schedules are established by the
principal’s contract with the shipper
• the joint responsibilities set out in federal and provincial licencing and related statutes
5) The principal and owner-operator state the relationship is a contract for service and not that of employer and
employee.
6) The principal doesn’t issue a Canada Revenue Agency T4, T4A or make statutory deductions for Employment
Insurance and/or Canada Pension Plan.

Part C – Courier and rideshare industry

Individuals will be treated as independent operators, for workplace safety and insurance purposes only, if they meet all
the following criteria:
1) The principal and the individual state the relationship is a contract for service and not that of employer and
employee. The individual does not use the principal company’s name except for licencing purposes or statutory
requirements on any vehicle. For security purposes, the individual can use removable photo identification.
2) The individual pays for the vehicle and more than 50 per cent of the operating expenses (e.g., gas,
maintenance, insurance, licence, pager, cell phone, parking tickets, towing).
3) The principal doesn’t control the individual’s operation, except in deciding what pick-ups and deliveries are
offered and what shippers’ instructions the principal provides.
4) The individual is free to perform pick-ups or deliveries for any other party at any time and is free to set their own
work schedule.
5) The principal does not issue a Canada Revenue Agency T4, T4A or make statutory deductions for Employment
Insurance and/or Canada Pension Plan.

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Declaration
To the best of my knowledge, information and belief, the information contained in this document is true.
I/we understand that the WSIB reserves the right to audit and verify these responses. If these responses do not truly
represent the nature of the working relationship, the WSIB may reverse the determination of status retroactively to the
date that the working relationship began.
By signing below, the individual acknowledges that if they experience a work-related injury or illness, they will not be
eligible for any WSIB benefits unless they request optional insurance coverage and the WSIB approves it.
Personal information on this form is collected under the authority of the Workplace Safety and Insurance Act and may
be used to register/determine your status for coverage and to administer and enforce the act.

First name Last name

Signature Date (dd/mmm/yyyy)

Street address

City Province Postal code Phone number

Authorizing name WSIB account

Principal name Position
and signature number

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 Optional insurance
request/change
Please complete this section in full except
where there is preprinted information.
Account number Firm number

Date

Requesting or changing optional insurance

To request optional insurance, please complete sections A and B.

To change the amount of existing optional insurance, please complete sections A and C.

Please also:
• provide proof of earnings (see below)
• have the applicant review and sign the optional insurance declaration (attached)
• have the owner’s certification completed and signed (attached)

Cancelling optional insurance

Individuals who are cancelling their optional coverage must complete section D or forward their request in writing to the
WSIB.

Proof of earnings
We accept the following documents (issued by the owner or authorized officer responsible for the account) as proof of
earnings.

For executive officers:

• T4s and T4As or any other document submitted to the Canada Revenue Agency (CRA) to report earnings

For sole proprietors and partners:

• audited financial statements prepared by a professionally designated accountant
• income tax returns with supportive income statements (T1, T2125, T2032, etc.) or other documents submitted to the
CRA to report business income

Please note:
• if the sole proprietor or partnership has been in business for less than one year, the amount of coverage for premium
benefit purposes is set at one-third of the annual maximum insurable earnings
• if the executive officer’s company has been in business for less than one year, the amount of coverage for premium
and benefit purposes is set at one-third of the annual maximum insurable earnings or the amount stated on the
optional insurance form
• if the applicant’s company has been in business for more than one year, the amount of coverage for premium and
benefit purposes must accurately reflect the applicant’s actual annual earnings, as supported by the documents
listed above
• coverage will not be provided if your operation shows a net business loss

Contact [email protected] if you require this communication in an alternative format.

Ce document est disponible en franҫais sous le titre : Demande ou modification d’assurance facultative 1574B (06/23)
wsib.ca | Mail: 200 Front Street West, Toronto, Ontario, M5V 3J1 | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050
1574A (06/23) Page 1 of 4
 wsib.ca

• loss of earnings benefits are not paid if your operation shows a net business loss despite active optional insurance
• the WSIB may deny the request (or coverage renewal) for optional insurance if the applicant can’t substantiate their
level of earnings

Any new requests for optional insurance or changes to the amount of optional insurance will take effect on the date we receive
the signed request and satisfactory proof of earnings. We require pre-payment for optional insurance premiums.

The amount of optional insurance will not be retroactively adjusted if the applicant receives benefits at an amount that is lower
than the amount of optional insurance.

Please call us at 1-800-387-0750 if you have any questions or require more information.

This form continues on the following page.

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Section A
First name Middle name Last name

Date of birth (dd/mmm/yyyy) Title/position with company

Home address (This address must be a physical address, not a box number or general delivery) City

Province Postal code Phone number Date business commenced (dd/mmm/yyyy)

Section B - Complete if requesting new optional insurance

Amount of coverage requested Today’s date (dd/mmm/yyyy)

Section C - Complete if requesting a change in the amount of existing optional insurance

Revised coverage amount requested Today’s date (dd/mmm/yyyy)

Section D - Complete if cancelling existing optional insurance

Name Today’s date (dd/mmm/yyyy)

Optional insurance declaration

Please read the following information carefully. It explains how optional insurance changes your status under the
Workplace Safety and Insurance Act (the Act).

I understand that:
1. O
 wners, partners, executive officers and independent operators are not automatically entitled to benefits under the
Act, unless they are included in expanded compulsory coverage in construction.

2. I am voluntarily requesting to be considered a worker by the WSIB by applying for optional insurance as I am exempt
from WSIB mandatory coverage.

3. I must have optional insurance for a minimum of three consecutive months.

4. With optional insurance, I am entitled to all benefits workers receive.

5. I am giving up my right to sue workers and businesses whose industries are covered under Schedule 1 of the Act for
damages sustained in a workplace injury.

6. I must send the WSIB proof of earnings when first requesting optional insurance.

7. If my earnings level changes, I must send the WSIB a signed request to revise the amount of insurance coverage,
along with proof of earnings.

8. The WSIB may deny my request for coverage if I do not provide proof of earnings.

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9. The WSIB may request proof of earnings at any time.

10. The WSIB may adjust the amount of optional insurance that I request.

11. My optional insurance will continue beyond the minimum three months until either the WSIB or I cancel the insurance.

12. If I have a workplace injury, my optional insurance will remain in effect until I notify the WSIB, in writing, that I wish to
cancel it or that my status has changed to mandatorily covered.

13. If I have a workplace injury, my earnings at the time of my injury will be compared to the amount of my optional insurance.
The WSIB will base benefits on whichever is the lower amount - my earnings or my optional insurance coverage.

14. If I am paid benefits at an amount that is lower than the amount of my optional insurance, the amount of my optional
insurance will not be retroactively adjusted.

15. T
 he WSIB may cancel or deny renewal of my optional insurance if the business paying for it has amounts owing, or
the WSIB determines I am mandatorily covered under the Act. If any premium is owing on my optional insurance, the
amount of the unpaid premium may be deducted from my benefits.

16. T
 he effective date for new optional insurance requests, changes to or cancellations of optional insurance will either be
the date that the completed optional insurance request/change form is received by the WSIB, or the requested date,
whichever is later.

17. If the WSIB determines I am mandatorily covered, the effective date of changes to, or cancellation of, my optional
insurance may be made retroactively.

Applicant’s name Applicant’s signature Date (dd/mmm/yyyy)

Owner’s certification
I hereby certify that I am an owner (or authorized officer) responsible for this account. I also certify that the amount
of optional insurance requested accurately represents the earnings of the applicant.
I acknowledge that the accident costs associated with any work-related injuries for the applicant will be applied to
the accident record for this account.
Personal information on this form is collected under the authority of the Act, and may be used to register/determine
your status for coverage and to administer and enforce the Act. If you have any questions, please call 1-800-387-0750.

Name of owner or authorized officer Title

Signature Phone number Date completed (dd/mmm/yyyy)

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