Ontario Tribunal | WSIB: Forms – Power of Attorney for Property/Guardianship of Property  Form (3074A)

Power of Attorney for Property/Guardianship of Property  Form (3074A) – WSIB in Ontario

The Power of Attorney for Property/Guardianship of Property  Form (3074A) form is intended to establish and document the authority of an attorney or guardian to act on behalf of a worker or survivor concerning their property. It must be completed, printed, signed, and attached to the legal documents authorizing such actions. This form ensures that the Workplace Safety and Insurance Board (WSIB) has accurate and complete information about the attorney or guardian authorized to manage the property affairs of the worker or their survivor.

This form is used to document the authority of an attorney or guardian to act on behalf of a worker or survivor regarding their property with WSIB in Ontario. Follow these instructions to complete the form correctly.

Step-by-Step Instructions

Obtain the Necessary Documents

1. • Ensure you have the legal document that authorizes you to act on the worker’s or survivor’s behalf concerning their property.
   • Gather any additional documents required by the conditions outlined in the legal document.

Fill Out Worker and Claim Information

1. • Worker’s Last Name: Enter the worker’s last name.
   • Worker’s First Name: Enter the worker’s first name.
   • Claim Number: Enter the WSIB claim number associated with the worker.

Provide Attorney/Guardian Details

1. • List the names, signatures, and contact information of all parties acting as attorney/guardian.
   • If a substitute is acting as attorney/guardian, provide the substitute’s information.

Use the Back of the Form (if needed)

1. • Add extra contact information and signatures if there are more than two attorneys/guardians.
   • List any additional claim numbers if the worker/survivor has other claims.

Confirm Authority

1. • Print the name of the person who authorized you to act on their behalf. This should be the name as it appears in the legal document.
   • Fill in your contact information as the attorney/guardian:
     • Attorney/Guardian Name: Print your full name.
     • Street No., Street Name, Apt./Suite No.: Enter your complete address.
     • Town/City, Province/State, Postal Code/Zip Code, Country: Enter your city, province/state, postal/zip code, and country.
     • Telephone Numbers: Provide your phone numbers (daytime, evening, and cell phone).
     • Signature and Date: Sign and date the form (use the format dd/mmm/yyyy).

Repeat for Additional Attorneys/Guardians

1. • If there is more than one attorney/guardian, repeat the above steps for each additional person.

Attach Required Documents

1. • Attach the completed and signed form to the front of the legal document authorizing you to act on behalf of the worker or survivor.
   • Include any other required documents as specified by the conditions in the legal document.

Submit the Form

1. • Ensure all information is accurate and the form is signed.
   • Note that this form alone is not a valid Power of Attorney document; it must be accompanied by the actual legal document.
   • Mail the completed form and attached documents to:

Workplace Safety and Insurance Board

200 Front Street West

Toronto, Ontario

Canada M5V 3J1

Tips

• Ensure Completeness: Double-check that all fields are filled out completely and correctly.
• Multiple Claims: Use the back of the form for listing additional claims and extra contact information if necessary.
• Legibility: Print all information clearly to avoid any misunderstandings.
• Legal Document: Always attach the legal document that grants you authority along with this form.

By following these steps, you will ensure that the WSIB has all the necessary information to recognize your authority as an attorney or guardian for the property of the worker or survivor.