Unpaid Work Placement Accident Report Form

In the event that you are injured during the course of your duties at your placement, insurance coverage is triggered by first reporting your accident to Safety, Health, Environment and Risk Management (SHERM) using the Unpaid Work Placement Accident Report Form. Complete this accident report form as soon as reasonably possible following your injury. Contact your Laurier placement coordinator or SHERM for further information.

Insurance coverage through the Ministry of Training, Colleges and Universities (MTCU) is provided under one of two programs:

1. Student placements with placement employers covered by the Workplace Safety and Insurance Board (WSIB) are provided WSIB insurance coverage by the MTCU.

2. Student placements with placement employers not covered by the Workplace Safety and Insurance Board are covered through a private insurance policy purchased by MTCU.

SHERM will work with you, your Laurier placement coordinator and your placement employer to submit the necessary claim forms on your behalf. In order to complete this process, you will also be required to complete and sign an MTCU Postsecondary Student Unpaid Work Placement Workplace Insurance Claim form, which will be provided to you once your accident report is received.

Complete this form in the event of a workplace accident incurred by a student participating in an unpaid work placement which required seeking health care from a physician. The report should be completed as soon as reasonably possible following the injury.

If you have questions, contact Donna Kubica at dkubica@wlu.ca.