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620-BHE-01-IGOT
WSPS Health and Safety Excellence program
WSPS Health and Safety Excellence program
APPLICATION FORM
Submit electronic application to: excellenceprogram@wsps.ca
Firm (full name):
Parent Company (if any):
WSIB Account Number*: How many locations are covered
by this WSIB Account Number?*
Predicability Level (if known):
LOW (equal to or less than 20%)
HIGH (greater than 20%)
Annual WSIB Premiums: Number of Employees:
Address:
City/Town: Province: Postal Code:
Contact Name (please print): Contact Title:
Telephone Number: Email Address:
* Firms are required to implement all chosen topics at every location covered by the account.
Registration Fees
Prices are per WSIB account number. Complete one application for each WSIB account number. Registration
fees are based on the amount of premiums a firm paid in the prior year. Please check off the appropriate fee
category, based on your premium amounts.
Small Firm
Employer Premiums < $100K
$800 +HST
Medium Firm
Employer Premiums
$100K to < $1 Million
$1,700 +HST
Large Firm
Employer Premiums > $1M
or Schedule 2 Firms
$2,500
+HST
