The following forms are available for workers and employers. If you require more information please refer to the contact page.

Mohawk Self Insurance Forms

MSI Policy – (April 2018)
Instructions for the completion of MSI-A form
Instructions for the completion of MSI injury forms
Instructions for the completion of the MSI Safe Maternity forms
MSI-A form – MSI Registration Form
MSI-Ae form – Subsidy Program Application Form
MSI-Be form – Subsidy Program Worker’s Information Form
MSI-1 form – Worker’s Claim Form
MSI-2 form – Employers Form
MSI-3 form – Physician’s Report Form
MSI-4 form – Safe Maternity Program
MSI-8 form – Medical Update Form
MSI-16e form – Employer Subsidy Salary Reimbursement Request Form
MSI 18 form – Accident Investigation Report form
MSI-21 form – Temporary Work Assignment Form

Certification & Competency

Contractors Certification Certificate Application Form
Workers Certification Card Application Form

Occupational Safety & Health

Notice of Alleged Safety or Health Hazards Form