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COR Extension Request Form

COR Extension Request Form

To request an extension on your COR audit, please complete the following form.

Disclaimer: extension requests will be approved by the WorkSafely Director. You will receive formal confirmation of your request should it be approved.

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City Province Postal Code

Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

WCB account number(Required)

COR Number(Required)

COR Anniversary Date(Required)

MM slash DD slash YYYY

Extension date requested (cannot exceed 60 days)(Required)

MM slash DD slash YYYY

Reason for extension(Required)

Unit 3 – 1680 Ellice Ave.
Winnipeg, MB R3H 0Z2
P 204-947-1379
F 204-943-2279

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