Employment Standards Claim Form

Employment Standards Employment Standards
Claim Form
Ministry of Labour

Your Name: Telephone No.
Please be sure you have read the “Before You Start” booklet before filling out the Claim Form.
Use a pen to fill out the form. PRINT as clearly as possible. Please use blue or black ink only.
Collective Agreement
Detailed instructions on how to fill out this section can be found on page 9 of the Claim Guide.
Were you covered by a collective agreement when the matter you are claiming about happened? *
Yes No Do not know
If “Yes”, contact your union representative for assistance. Generally, you cannot file a claim with the Ministry of Labour.
Section A1 – Information About Your Experience Contacting Your Employer
Detailed instructions on how to fill out Sections A1 through A4 can be found on pages 10 to 13 of the Claim Guide.
Did you already contact your employer? *
Yes If “Yes”, please GO TO section A2.
No If “No”, please GO TO section A3.
Section A2 – Yes, I Tried to Contact my Employer
How did you contact your employer? (Choose all that apply) *
Phone In person By letter Email
Other:
When did you try to contact your employer? *
Note: Please wait a few days to give your employer a chance to get back to you (e.g. 7 to 10 days)
What Employment Standards issue(s) did you contact your employer about? *
What did your employer say? (Please check one box and provide some details about your employer’s response in the
space provided) *
Refused to help Did not say anything Other
Explain:
Section A3 – No, I Have Not Contacted my Employer
Your claim may still be investigated if you have a good reason for not contacting your employer. The following are generally
considered to be good reasons for not contacting your employer. Please check the box(es) that apply to you: *
You already tried to contact your employer.
The money owed to you is from 5 months ago or more
(there are time limits to file).
Your workplace has closed down.
Your employer has gone bankrupt.
You are afraid to do so.
Your issue does not involve money.
MOL-ES-002E (2010/08)
You are or were working as a live-in caregiver.
You have difficulty with communicating in the language
spoken by your employer.
You are a young employee.
You have a disability that makes it difficult for you to
contact your employer.
There is any reason relating to a ground under the
Ontario Human Rights Code.
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Your Name: Telephone No.
Other (explain):
Section A4 – Information About You
Last (Family) Name * Mr. Miss
Mrs. Ms
First (Given) Name *
Mailing Address *
Street Number *
Rural Route
Province/State *
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Suffix (e.g. A)
PO Box
Home Telephone Number
Daytime Telephone Number
Email Address
Commonly Used First Name
(if applicable)
Street Name *
Postal Station
Postal Code/Zip Code *
Previous Last (Family) Name (if your employer knows you by
that name)
City/Town *
Country
Middle
Initial(s)
Type
Cell Telephone Number
Students Only: Date of Birth
(yyyy/mm/dd)
Direction
Who can we leave a message with concerning your claim at the daytime telephone number?
What is the best way to reach you between 9:00 am and 5:00 pm on weekdays?
Home Telephone Number Cell Telephone Number Daytime Telephone Number Email Address
Other Mailing Address
Same as above
Street Number
Rural Route
Province/State
Suffix (e.g. A)
PO Box
Street Name
Postal Station
Postal Code/Zip Code
City/Town
Country
Type
Direction
Do you authorize anyone to act on your behalf? (for example family member, friend, legal counsel)
Yes (please fill in the contact information section below)
Name of the person
Relationship to you
Unit
Unit
Telephone Number
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Your Name: Telephone No.
Section B1 – Information about the Employer
Detailed instructions on how to fill out Section B1 can be found on pages 13 to 15 of the Claim Guide.
IMPORTANT: Is your claim submission related to a temporary help agency? *
Yes If “Yes”, please provide information about the temporary help agency in sections B1 and B2.
No
Employer’s Business Name (Please provide the legal name or name of company) *
If this business operates using any other name(s), please provide these name(s)
Type of Business
Business Number (This is in reference to your employer’s Canada Revenue Agency Business Number. See page 26 of
the Claim Guide for more information)
This business is: Still operating No longer operating In receivership or bankruptcy Do not know
If in receivership/bankruptcy, provide the receiver or trustee’s name
If your employer is bankrupt or in receivership, and your employment has been terminated, please consult the federal
government’s Wage Earner Protection Program website www.servicecanada.gc.ca/eng/sc/wepp/index.shtml for more
information on money you may be entitled to receive.
Address of Employer (For tips on finding your employer’s address, GO TO page 14 of the Claim Guide) *
Street Number *
Rural Route
Province/State *
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Suffix (e.g. A)
PO Box
Street Name *
Postal Station
Postal Code/Zip Code *
City/Town *
Country
I don’t know my employer’s address (Please explain in section D2).
Address of the location where you work(ed)
Same as above
Street Number
Rural Route
Province
Suffix (e.g. A)
PO Box
Street Name
Postal Station
Additional Information about the Employer
Employer’s Email Address
Name of your supervisor, or contact
City/Town
Postal Code
Employer’s Website
Type
Type
Employer’s Telephone Number
Direction
Direction
Unit
Unit
Employer’s Fax Number
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Your Name: Telephone No.
Section B2 – Your Work History with the Employer
Detailed instructions on how to fill out Section B2 can be found on pages 15 to 17 of the Claim Guide.
NOTE: If you have no work history with the employer, leave this section blank. (See page 15 of the Claim Guide for
more information about these situations)
What was your job title? What kind of work did you do?
Do you have a record of your hours of work? (e.g. in a diary or calendar) Yes No
Did you work the same number of hours each day?
No If “No”, please explain:
Yes If “Yes”, please answer the following three questions:
How many hours did you work each
day?
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How many days did you work each
week?
Total number of hours worked each
week?
Pay Period Weekly Every two weeks Twice a month Once a month
Other (explain)
How were you paid? Per hour Salary Commission Piecework
Other (explain)
Rate of pay before
deductions (choose
Per hour $ Per week $ Per annum (year) $
one) Other (explain)
When did you start working for this employer? Current status: *
(yyyy/mm/dd)
Still working for this employer
Other (explain)
Fired Laid Off Quit
Last day you worked for this employer?
(yyyy/mm/dd)
Date notice of termination was received?
(yyyy/mm/dd)
Did you receive notice of termination before your last day of work?
Yes No N/A
The notice was:
Written Oral I don’t know N/A
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Your Name: Telephone No.
IMPORTANT: Are you claiming that a client of the temporary help agency punished or threatened to
penalize you for asking for or asking about your rights under the Employment Standards Act, 2000? *
Yes If “Yes”, please fill out section C1 below.
No If “No”, please GO TO section D1 on page 7.
Section C1 – Reprisal: Information about the Client
Detailed instructions on how to fill out Section C1 can be found on pages 18 to 19 of the Claim Guide.
Client Business Name (Please provide the legal name or name of company) *
If this business operates using any other name(s) please provide these name(s)
Type of Business
This client is: Still operating No longer operating In receivership/bankrupt Do not know
If in receivership/bankruptcy, provide the receiver or trustee’s name
Address of the Client Location Where You Work(ed) *
Street Number * Suffix (e.g. A) Street Name *
Rural Route
Province *
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PO Box
Postal Station
I don’t know the address of where I worked
Additional Information about the Client
Client Email Address
Name of your supervisor, or other contact
City/Town *
Type
Postal Code *
Client Website
Client Telephone Number
Direction
Unit
Client Fax Number
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Your Name: Telephone No.
Section C2 – Your Work History with the Client
Detailed instructions on how to fill out Section C2 can be found on pages 19 to 20 of the Claim Guide.
NOTE: If you have no work history with the Client, please GO TO section D1.
What was your job title? What kind of work did you do for the client?
Do you have a record of your hours of work? (e.g. in a diary or calendar) Yes No
Did you work the same number of hours each day?
No If “No”, please explain:
Yes If “Yes”, please answer the following three questions:
How many hours did you work each
day?
When did you start working for this client? (yyyy/mm/dd)
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How many days did you work each
week?
Total number of hours worked each
week?
When did you finish working for this client? (yyyy/mm/dd)
I am still working for the same client.
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Your Name: Telephone No.
Section D1– Details About Your Claim
Detailed instructions on how to fill out Section D1 can be found on pages 20 to 25 of the Claim Guide.
Please tell us which employment standard(s) you are claiming and provide an estimate of the amount you are
owed. You will be asked to answer questions about each employment standard you are claiming in section D2.*
Employment Standard Estimate Amounts ($)
Unpaid Wages
Overtime Pay
Vacation Pay / Vacation Time
Public Holidays / Public Holiday Pay
Deductions from Wages
Minimum Wage
Termination Pay
Severance Pay
Temporary Help Agency charged prohibited fees
Temporary Help Agency did not provide required information
Temporary Help Agency restricted the Client from hiring you or
providing you with references
Limits on Hours of Work / Eating Periods / Rest Periods (between
shifts, daily, weekly or biweekly)
Leaves of Absence (Pregnancy, Parental, Family Medical, Organ
Donor, Personal Emergency, Reservist)
Reprisal by the Employer (which includes a Temporary Help Agency)
Reprisal by the Client of the Temporary Help Agency:
Check this box ONLY if you work(ed) for a temporary help agency AND
if you are claiming a reprisal by the Client. Please ensure that you have
completed Section C.
Other (specify):
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Your Name: Telephone No.
Section D2 – Background Information About Your Claim
Detailed instructions on how to fill out Section D2 can be found on pages 25 to 30 of the Claim Guide.
Tell us why you are filing a claim submission. To help tell your story, please see the questions on the next page.
Please try your best to answer the questions in full sentences. You do not have to answer all the questions.
Only answer the questions about the employment standard(s) you are claiming. For example, if your claim is
about overtime pay and public holiday pay, answer the questions outlined under the headings “Overtime Pay”
and “Public Holidays / Public Holiday Pay”. If there is other information you feel might help explain what
happened, please tell us in this section.
Provide as much relevant detail as possible about which employment standards have been violated, including
the dates on which those violations occurred. If you need more space, please attach additional pages to your
claim. Write your name on each page, and telephone number if possible. *
MOL-ES-002E (2010/08)
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Your Name: Telephone No.
Section D2 – Background Information About Your Claim
Please answer the questions that relate only to the employment standard(s) you are claiming in the space provided
in D2. You do not have to answer all the questions. For example if your claim relates to overtime pay and public
holidays, answer the questions under overtime and public holidays.
Unpaid Wages Temporary Help Agency charged prohibited fees
� What days/hours/work were you not paid for?
� Were you unable to cash your pay cheque?
� What is the amount of wages you are owed?
� Please provide any other information you feel would
clarify any disputes about the wages you are claiming.
Overtime Pay
� When were you not paid overtime?
� Do you have an agreement that your employer will pay
overtime after a certain number of hours? If yes, tell us
the number of hours.
Vacation Pay / Vacation Time
� Did you not get vacation pay, vacation time or both?
� Have you received any vacation pay or vacation time
off? If yes, please indicate when you received it and how
much time and/or pay you received.
Public Holidays / Public Holiday Pay
� For which holiday(s) did you not receive time off and/or pay?
� Did you agree to work on the public holiday(s) in question?
� Did you receive any substitute days off?
� Did you work your shifts before and after the holiday(s)?
If no, please explain why.
Deductions from wages Leaves of Absence
� What deductions were made?
� Did you give your employer permission to make these
deductions? If yes, explain.
� How much was deducted and when?
Minimum Wage
� When were you not paid minimum wage?
� How many hours do you normally work in each pay
period, and how much do you usually get paid?
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� What fees were charged?
� What was the amount of fee(s) charged?
� When were the fee(s) charged?
Temporary Help Agency did not provide required
information
� What information did you not receive?
� On what date should you have received this
information?
Temporary Help Agency stopped the Client from
hiring you or providing you with references
� Briefly explain what happened, and when.
Limits on Hours of Work / Eating Periods / Rest
Periods (between shifts, daily, weekly or biweekly)
� Tell us about your hours of work issue.
� Do you receive breaks or eating periods? If yes, how
often do you take them and how long are they?
� When did this issue happen?
� What kind of leave of absence is your claim
submission about?
� Tell us the main events concerning your claim
submission.
Reprisal by the Employer (which includes a
Temporary Help Agency)
� Tell us what happened with your employer.
� Tell us the main events that led to your employer
threatening or penalizing you.
Termination Pay and/or Severance Pay Reprisal by the Client of the Temporary Help Agency
� Did you get any notice before your employment ended?
If yes, how much?
� Did you receive any money when your employment
ended? If yes, how much?
� Did your employer tell you why he/she ended your
employment? If yes, please tell us.
� If you quit, please explain why.
� Please tell us the main events that led to your
employment ending.
� Tell us what happened with the client.
� Tell us the main events that led to the client
threatening or penalizing you.
Other (specify)
� Tell us about the employment standard(s) not already
identified above–what happened, and when?
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Your Name: Telephone No.
Section D3 – Supporting Documents
Detailed instructions on Section D3 can be found on page 30 of the Claim Guide.
Please tell us which of the following supporting documents you have. Once we review your claim
submission, we will ask you to send photocopies of relevant documents to the Ministry of Labour.
Please mark boxes with a check mark (�): *
I have these
documents
MOL-ES-002E (2010/08)
I do not
have these
documents
Document(s)
Business cards, letterhead, or job ads. These documents will have information about
your employer’s address, phone number(s), email address and website.
Pay stubs for the periods you are claiming you are owed wages (including overtime
pay, vacation pay, public holiday pay, termination pay, severance pay, minimum
wage, or where an employer unlawfully deducted money from your wages).
Pay cheques, including those that have “bounced”, or are “NSF” (“non-sufficient
funds”).
Record of Employment form (ROE). This document will tell you the Employer’s
Business Number. If you have already given your ROE to Human Resources and
Skills Development Canada, contact them and ask for a photocopy (1-800-206-
7218).
Written contract of employment, if there is one.
Records of the hours you have worked (e.g. time sheets, attendance records,
calendar, diary, or notes).
T4 Slips.
Section E – Claimant’s Declaration
Documents related to a leave of absence (e.g. a medical certificate in the case
of a family medical leave).
Written notice of termination, if received.
Any receipts, invoices, or cancelled cheques relating to fees charged by the
Temporary Help Agency.
Any other documents that help with the investigation.
I declare that, to the best of my knowledge, this information is accurate.
This claim must be signed and dated. *
Name
Signature Date (yyyy/mm/dd)
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MOL-ES-002E (2010/08)
Ministry of Labour
Employment Standards Program
Collection, use and disclosure of personal information
Employment Standards Act
Claim
Any information, either written or spoken, that you give to the Ministry of Labour in support of your claim,
including the information provided on the claim form, is collected under the authority of the Employment
Standards Act, 2000 to assist in the investigation of alleged violations of the Employment Standards Act,
2000. The Freedom of Information and Protection of Privacy Act, R.S.O. 1990 F.31 (as amended) governs
the collection, use and disclosure of this information.
Any information that you give to an employment standards officer that is relevant to your claim and is
considered necessary for the investigation and enforcement of the claim may be shared with your employer
or the employer’s representative.
The Ministry of Labour or its agent may contact you for the purposes of conducting a survey about the
quality of the ministry’s service. Any information you give to the Ministry of Labour that is necessary to
conduct the survey may be shared with the ministry’s agent.
If you have any questions about the collection, use and disclosure of personal information by the Ministry of
Labour, you may telephone 416-326-7786 or write to:
Ministry of Labour
Freedom of Information and Privacy Office
400 University Ave., 10th Floor
Toronto ON M7A 1T7
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MOL-ES-002E (2010/08)
Your Name:
Send your fully-completed claim form to the Ministry of
Labour and receive your claim submission number
Please look over your claim form to ensure that you have filled out all necessary sections,
including section D2.
Please write your name at the top of each page, and include your telephone number, if
possible.
Once your claim form has been processed, you will receive a claim submission number.
NOTE: Only send pages 1 to 10 of this claim form to the Ministry of Labour.
You can file your claim form in person at a ServiceOntario Centre or by fax or mail.
Your claim form can be sent to the Ministry of Labour as follows:
By fax at 1-888-252-4684.
In person at a ServiceOntario Centre (1-800-267-8097).
By mail to:
Provincial Claims Centre
Ministry of Labour
70 Foster Drive, Suite 410
Roberta Bondar Place
Sault Ste. Marie ON P6A 6V4
Note: If you file your claim submission by fax, in person, or by mail, you will receive a letter in the mail with
your claim number once all of your required information has been verified. If your claim submission is
missing required information, you will receive a letter in the mail with your claim submission number, and a
request to provide more information.
A claim submission number is assigned as soon as the ministry receives and registers your Claim Form. You
will be provided with a claim number and your claim will be assigned for investigation once the ministry has
verified that all required information has been completed.
Please only file your claim once. For example, if you have filed your claim submission online, please do
not send another copy of your claim form to the Ministry of Labour.
Write your name on the envelope and on each page that you mail.
Once you receive your claim submission number, make sure you keep it in a safe place.
Please contact the Ministry of Labour immediately, with your claim submission number, if:
� You change your address, phone number, or email address;
� You and your employer resolve all or part of your claim; or
� You want to add information to your claim.
�
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Employment Standards
Claim Form
© Queens Printer for Ontario, 2010
ISBN 978-1-4435-2934-1 (Print)
ISBN 978-1-4435-2935-8 (PDF)
Le présent document est aussi disponible en français sous le titre – «Normes d'emploi Formulaire de
réclamation » [ISBN 978-1-4435-2936-5 (imprimé) et ISBN 978-1-4435-2937-2 (PDF)].