Tribunal Ontario | WSIB: Forms – Direct Deposit Request (3072A)

Direct Deposit Request (3072A) – WSIB in Ontario

The WSIB Direct Deposit Request Form (3072A) is a confidential document used by claimants to authorize the Workplace Safety and Insurance Board (WSIB) in Ontario to deposit eligible payments directly into their Canadian bank accounts. The WSIB Direct Deposit Request Form (3072A) ensures that all eligible payments under the Workplace Safety and Insurance Act, 1997, and WSIB’s Operational Policy Manual are deposited directly into the claimant’s account, with certain exceptions issued by cheque. The form emphasizes the confidentiality and accuracy of the provided information, and the importance of notifying WSIB of any changes in circumstances.

Filling this form out ensures that your eligible payments from the Workplace Safety and Insurance Board are directly deposited into your Canadian bank account. Follow these step-by-step instructions to complete the form accurately:

Step-by-Step Instructions

Claim Number and Claimant Information

1. • Locate the section at the top of the form.
   • Claim Number: Enter your WSIB claim number.
   • Claimant’s Name and Address: Provide your full name and current mailing address.

Select and Complete Either Option A or B

1. • You must choose only one of the two options to provide your bank account details.

Option A: Provide a Void Cheque

1. • Obtain a cheque from your cheque book that has your name pre-printed by your financial institution.
   • Write “VOID” across the front of the cheque.
   • Attach the voided cheque to the form.

Option B: Pre-authorized Direct Deposit Form

1. • Visit your financial institution and request a pre-authorized direct deposit form.
   • Ensure the form includes your name, account details, and the financial institution’s pre-printed information.
   • Write your WSIB claim number, name, and signature on the pre-authorized direct deposit form.
   • Attach the completed pre-authorized direct deposit form to the WSIB direct deposit request form.

Sign the Form

1. • Signature of Bank Account Owner: Sign your name in the designated area to confirm that all information provided is accurate and truthful.
   • Date: Enter the date you are signing the form.
   • Telephone: Provide your current phone number.
   • If the account is a joint account, the co-owner must also sign and provide their telephone number.

Return the Form to WSIB

1. • You can submit the completed form in one of the following ways:
     • Fax: Send the form to 416-344-4684 or 1-888-313-7373.
     • Mail: Mail the form to the following address: Workplace Safety and Insurance Board
       200 Front Street West
       Toronto, ON M5V 3J1

Additional Information

• Direct Deposit Availability: This service is only available for accounts held at Canadian financial institutions.
• Confidentiality: The form ensures that your banking information is kept confidential. However, if your account is a joint account, other account holders may have access to the funds.
• Change in Circumstances: Inform WSIB immediately if there are any changes in your circumstances, such as a change of address or account details.

Contact Information for Assistance

• Accessibility Requests: If you require the form in an alternative format, email accessibility@wsib.on.ca.
• General Inquiries: Visit wsib.ca or call toll-free at 1-800-387-0750.
• TTY (for hearing impaired): 1-800-387-0050.

By following these instructions, you can ensure that your WSIB direct deposit form is filled out correctly and processed efficiently.