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				<Property Name="Content"><![CDATA[Section E: Declaration			I declare that all the information is true and correct tot he best of my knowledge]]></Property>
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				<Property Name="Content"><![CDATA[D]]></Property>
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				<Property Name="Content"><![CDATA[M ]]></Property>
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				<Property Name="Content"><![CDATA[Y ]]></Property>
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				<Property Name="Content"><![CDATA[D]]></Property>
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				<Property Name="Content"><![CDATA[M ]]></Property>
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				<Property Name="Content"><![CDATA[Y ]]></Property>
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				<Property Name="Content"><![CDATA[5. Name of healthcare provider: ]]></Property>
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				<Property Name="Content"><![CDATA[6.  How did the injury happen? ]]></Property>
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				<Property Name="Content"><![CDATA[7.  Has the employee lost time from work, due to the injury, after the day of injury? ]]></Property>
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				<Property Name="Content"><![CDATA[No]]></Property>
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				<Property Name="Content"><![CDATA[Yes]]></Property>
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				<Property Name="Content"><![CDATA[If 'No' go to Section E]]></Property>
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				<Property Name="Content"><![CDATA[8.  First day off and time employee left work due tot his injury]]></Property>
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				<Property Name="Content"><![CDATA[D]]></Property>
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				<Property Name="Content"><![CDATA[Y ]]></Property>
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				<Property Name="Name"><![CDATA[Text54]]></Property>
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				<Property Name="Content"><![CDATA[M ]]></Property>
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				<Property Name="Content"><![CDATA[Time:]]></Property>
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				<Property Name="Content"><![CDATA[am]]></Property>
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				<Property Name="Content"><![CDATA[pm]]></Property>
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				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[am]]></Property>
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				<Property Name="Content"><![CDATA[Time:]]></Property>
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				<Property Name="Content"><![CDATA[Y ]]></Property>
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				<Property Name="Content"><![CDATA[M ]]></Property>
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				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[D]]></Property>
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				<Property Name="Content"><![CDATA[10  Do you have any reason to believe that this is not a work-related incident?]]></Property>
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				<Property Name="Content"><![CDATA[No]]></Property>
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				<Property Name="Content"><![CDATA[Yes]]></Property>
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				<Property Name="Content"><![CDATA[If 'yes', provide attachment(s) with explanation. ]]></Property>
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				<Property Name="Content"><![CDATA[11.  How is the employee paid?]]></Property>
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				<Property Name="Name"><![CDATA[Text75]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[If Regular Salary:]]></Property>
			</Group>
			<Group Name="Text76">
				<Property Name="Name"><![CDATA[Text76]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Hourly:]]></Property>
			</Group>
			<Group Name="Text77">
				<Property Name="Name"><![CDATA[Text77]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[$]]></Property>
			</Group>
			<Group Name="Text78">
				<Property Name="Name"><![CDATA[Text78]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[per hour,]]></Property>
			</Group>
			<Group Name="Text79">
				<Property Name="Name"><![CDATA[Text79]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[per week]]></Property>
			</Group>
			<Group Name="Text80">
				<Property Name="Name"><![CDATA[Text80]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[If Monthly:]]></Property>
			</Group>
			<Group Name="Text81">
				<Property Name="Name"><![CDATA[Text81]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[$]]></Property>
			</Group>
			<Group Name="Text82">
				<Property Name="Name"><![CDATA[Text82]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[If Non-Regular:]]></Property>
			</Group>
			<Group Name="Text83">
				<Property Name="Name"><![CDATA[Text83]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Sub-Contractor]]></Property>
			</Group>
			<Group Name="Text84">
				<Property Name="Name"><![CDATA[Text84]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Piecework]]></Property>
			</Group>
			<Group Name="Text85">
				<Property Name="Name"><![CDATA[Text85]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Owner/Operator]]></Property>
			</Group>
			<Group Name="Text86">
				<Property Name="Name"><![CDATA[Text86]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Other]]></Property>
			</Group>
			<Group Name="Text87">
				<Property Name="Name"><![CDATA[Text87]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Casual]]></Property>
			</Group>
			<Group Name="Text88">
				<Property Name="Name"><![CDATA[Text88]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[12.  Provide gross earnings for the 12 months preceeding the first day off work due to injury, starting with the most recent complete pay period. If less ]]></Property>
			</Group>
			<Group Name="Text89">
				<Property Name="Name"><![CDATA[Text89]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[ than 12 months, show earnings for actual period.]]></Property>
			</Group>
			<Group Name="Text90">
				<Property Name="Name"><![CDATA[Text90]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Gross earnings $]]></Property>
			</Group>
			<Group Name="Text91">
				<Property Name="Name"><![CDATA[Text91]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[from]]></Property>
			</Group>
			<Group Name="Text92">
				<Property Name="Name"><![CDATA[Text92]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[to]]></Property>
			</Group>
			<Group Name="Text93">
				<Property Name="Name"><![CDATA[Text93]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[D]]></Property>
			</Group>
			<Group Name="Text94">
				<Property Name="Name"><![CDATA[Text94]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Y ]]></Property>
			</Group>
			<Group Name="Text95">
				<Property Name="Name"><![CDATA[Text95]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[M ]]></Property>
			</Group>
			<Group Name="Text96">
				<Property Name="Name"><![CDATA[Text96]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[D]]></Property>
			</Group>
			<Group Name="Text97">
				<Property Name="Name"><![CDATA[Text97]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Y ]]></Property>
			</Group>
			<Group Name="Text98">
				<Property Name="Name"><![CDATA[Text98]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[M ]]></Property>
			</Group>
			<Group Name="Text99">
				<Property Name="Name"><![CDATA[Text99]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[13.  Time lost during the gross earning period due to:]]></Property>
			</Group>
			<Group Name="Text100">
				<Property Name="Name"><![CDATA[Text100]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[(c) Lack of work]]></Property>
			</Group>
			<Group Name="Text101">
				<Property Name="Name"><![CDATA[Text101]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[(b) Prior WCB claims]]></Property>
			</Group>
			<Group Name="Text102">
				<Property Name="Name"><![CDATA[Text102]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[(a) Unpaid sickness]]></Property>
			</Group>
			<Group Name="Text103">
				<Property Name="Name"><![CDATA[Text103]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[days]]></Property>
			</Group>
			<Group Name="Text104">
				<Property Name="Name"><![CDATA[Text104]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[days]]></Property>
			</Group>
			<Group Name="Text105">
				<Property Name="Name"><![CDATA[Text105]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[14.  Normal working hours for employee:]]></Property>
			</Group>
			<Group Name="Text106">
				<Property Name="Name"><![CDATA[Text106]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[(d) Other]]></Property>
			</Group>
			<Group Name="Text107">
				<Property Name="Name"><![CDATA[Text107]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[days, explain]]></Property>
			</Group>
			<Group Name="Text108">
				<Property Name="Name"><![CDATA[Text108]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[from]]></Property>
			</Group>
			<Group Name="Text109">
				<Property Name="Name"><![CDATA[Text109]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[to]]></Property>
			</Group>
			<Group Name="Text110">
				<Property Name="Name"><![CDATA[Text110]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[pm]]></Property>
			</Group>
			<Group Name="Text111">
				<Property Name="Name"><![CDATA[Text111]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[am]]></Property>
			</Group>
			<Group Name="Text112">
				<Property Name="Name"><![CDATA[Text112]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[pm]]></Property>
			</Group>
			<Group Name="Text113">
				<Property Name="Name"><![CDATA[Text113]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[am]]></Property>
			</Group>
			<Group Name="Text114">
				<Property Name="Name"><![CDATA[Text114]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[No]]></Property>
			</Group>
			<Group Name="Text115">
				<Property Name="Name"><![CDATA[Text115]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Yes]]></Property>
			</Group>
			<Group Name="Text116">
				<Property Name="Name"><![CDATA[Text116]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Shift work involved]]></Property>
			</Group>
			<Group Name="Text117">
				<Property Name="Name"><![CDATA[Text117]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[15.  Does the employee have regular days off?]]></Property>
			</Group>
			<Group Name="Text118">
				<Property Name="Name"><![CDATA[Text118]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[No]]></Property>
			</Group>
			<Group Name="Text119">
				<Property Name="Name"><![CDATA[Text119]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Yes]]></Property>
			</Group>
			<Group Name="Text120">
				<Property Name="Name"><![CDATA[Text120]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[If 'yes', circle which days off: ]]></Property>
			</Group>
			<Group Name="Text121">
				<Property Name="Name"><![CDATA[Text121]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Wed]]></Property>
			</Group>
			<Group Name="Text122">
				<Property Name="Name"><![CDATA[Text122]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Tue]]></Property>
			</Group>
			<Group Name="Text123">
				<Property Name="Name"><![CDATA[Text123]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Mon]]></Property>
			</Group>
			<Group Name="Text124">
				<Property Name="Name"><![CDATA[Text124]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Sat]]></Property>
			</Group>
			<Group Name="Text125">
				<Property Name="Name"><![CDATA[Text125]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Fri]]></Property>
			</Group>
			<Group Name="Text126">
				<Property Name="Name"><![CDATA[Text126]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Thu]]></Property>
			</Group>
			<Group Name="Text127">
				<Property Name="Name"><![CDATA[Text127]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Sun]]></Property>
			</Group>
			<Group Name="Text128">
				<Property Name="Name"><![CDATA[Text128]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[If 'no', circle the days off for the month of the injury, plus one month prior and one month after first day off due to the injury. ]]></Property>
			</Group>
			<Group Name="Text129">
				<Property Name="Name"><![CDATA[Text129]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[MONTH AFTER INJURY PERIOD]]></Property>
			</Group>
			<Group Name="Text130">
				<Property Name="Name"><![CDATA[Text130]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[MONTH OF THE INJURY]]></Property>
			</Group>
			<Group Name="Text131">
				<Property Name="Name"><![CDATA[Text131]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[ONE MONTH BEFORE INJURY PERIOD]]></Property>
			</Group>
			<Group Name="Text132">
				<Property Name="Name"><![CDATA[Text132]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31]]></Property>
			</Group>
			<Group Name="Text133">
				<Property Name="Name"><![CDATA[Text133]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31]]></Property>
			</Group>
			<Group Name="Text134">
				<Property Name="Name"><![CDATA[Text134]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31]]></Property>
			</Group>
			<Group Name="Text135">
				<Property Name="Name"><![CDATA[Text135]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[16.  TD1 Exemptions:]]></Property>
			</Group>
			<Group Name="Text136">
				<Property Name="Name"><![CDATA[Text136]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Spouse]]></Property>
			</Group>
			<Group Name="Text137">
				<Property Name="Name"><![CDATA[Text137]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Single]]></Property>
			</Group>
			<Group Name="Text138">
				<Property Name="Name"><![CDATA[Text138]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Other:  $]]></Property>
			</Group>
			<Group Name="Text139">
				<Property Name="Name"><![CDATA[Text139]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[No. Children 18 years or under]]></Property>
			</Group>
			<Group Name="Text140">
				<Property Name="Name"><![CDATA[Text140]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[if partial, provide: Provincial amount $:]]></Property>
			</Group>
			<Group Name="Text141">
				<Property Name="Name"><![CDATA[Text141]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Federal amount $:]]></Property>
			</Group>
			<Group Name="Text142">
				<Property Name="Name"><![CDATA[Text142]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[17.  Should compensation payments be made to:]]></Property>
			</Group>
			<Group Name="Text143">
				<Property Name="Name"><![CDATA[Text143]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Employer]]></Property>
			</Group>
			<Group Name="Text144">
				<Property Name="Name"><![CDATA[Text144]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Employee]]></Property>
			</Group>
			<Group Name="Text145">
				<Property Name="Name"><![CDATA[Text145]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[OR]]></Property>
			</Group>
			<Group Name="Text146">
				<Property Name="Name"><![CDATA[Text146]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[18.  Will employee be paid for satutory holidays?]]></Property>
			</Group>
			<Group Name="Text147">
				<Property Name="Name"><![CDATA[Text147]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Yes]]></Property>
			</Group>
			<Group Name="Text148">
				<Property Name="Name"><![CDATA[Text148]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[No]]></Property>
			</Group>
			<Group Name="Text150">
				<Property Name="Name"><![CDATA[Text150]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Y ]]></Property>
			</Group>
			<Group Name="Text151">
				<Property Name="Name"><![CDATA[Text151]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[M ]]></Property>
			</Group>
			<Group Name="Text152">
				<Property Name="Name"><![CDATA[Text152]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[D]]></Property>
			</Group>
			<Group Name="Text153">
				<Property Name="Name"><![CDATA[Text153]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Signature]]></Property>
			</Group>
			<Group Name="Text154">
				<Property Name="Name"><![CDATA[Text154]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Title]]></Property>
			</Group>
			<Group Name="Text155">
				<Property Name="Name"><![CDATA[Text155]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Name (please print)]]></Property>
			</Group>
			<Group Name="Text156">
				<Property Name="Name"><![CDATA[Text156]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Date:]]></Property>
			</Group>
			<Group Name="Text259">
				<Property Name="Name"><![CDATA[Text259]]></Property>
				<Property Name="Type"><![CDATA[Text Box]]></Property>
				<Property Name="Content"><![CDATA[Form 2008]]></Property>
			</Group>
		</Group>
	</Group>
</Report>