Ontario Tribunal | WSIB: Forms – General Worker Expense Form (3164A)

General Worker Expense Form (3164A) – WSIB in Ontario

The General Worker Expense Form (Form 3164A) is a document used by workers to claim expenses related to their WSIB (Workplace Safety and Insurance Board) claims. This form is not intended for medication reimbursement and must be accompanied by original receipts and prescriptions.

Filling out this form correctly is essential for processing your WSIB-related expense claims. Follow these step-by-step instructions to ensure all necessary information is provided:

Section A: Worker Information

Claim Number

1. • Enter your WSIB claim number in the designated space at the top of the form.

Personal Details

1. • Last Name: Enter your last name.
   • First Name: Enter your first name.
   • Initial: Enter your middle initial (if applicable).

Current Address

1. • Enter your current address, including street number and name.
   • City: Enter the name of the city where you reside.
   • Province: Enter the province.
   • Postal Code: Enter your postal code.

New Address

1. • If this is a new address, check the “Yes” box. If not, check the “No” box.

Contact Information

1. • Home Phone: Enter your home phone number.
   • Work Phone: Enter your work phone number.
   • Birth Date: Enter your birth date in the format mm/dd/yyyy.

Section B: Expense Information

Receipts and Prescriptions

1. • Attach all original receipts and prescriptions. Note that this form is not for medication reimbursement.

Expense Details:

1. • Date Purchased/Of Service: Enter the date when the service or product was purchased or provided in the format mm/dd/yyyy.
   • Amount: Enter the cost of the service or product in dollars.
   • Who Recommended this for you: Provide the name, address, and phone number of the person who recommended the service or product.
   • Description of Service/Product: Describe the service or product and the quantity.
   • Additional Comments: Enter any additional information that might be relevant.
   • Total Amount: Add up the costs of all services and products listed and enter the total amount in dollars.

Section C: Worker Declaration

Declaration Statement

1. • Read the declaration statement carefully. By signing this section, you certify that the information provided is true, accurate, and complete, and that the goods and/or services listed were received by you for your WSIB-related claim. You also agree to provide all original receipts to the WSIB and not to request reimbursement from any other insurers or organizations for these expenses.

Signature and Date

1. • Date: Enter the current date in the format mm/dd/yyyy.
   • Signature: Sign your name in the designated space.

Submission Instructions

Mail or Fax the Completed Form

1. • Mailing Address
     • 200 Front Street West
     • Toronto ON, M5V 3J1
   • Fax Numbers
     • 416-344-4684 or 1-888-313-7373

Contact Information for Assistance

1. • Telephone Numbers
     • 416-344-1000 or 1-800-387-0750

Additional Tips

• Ensure all fields are filled out accurately and completely.
• Double-check that all required original receipts and prescriptions are attached.
• Keep copies of all documents submitted for your records.

By following these instructions, you can ensure that your General Worker Expense Form (Form 3164A) is completed accurately, helping to expedite the processing of your WSIB expense claims.