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Number INS5186
Title Small Weeks Questionnaire
Purpose Please complete this form to provide us with your small weeks of insured earnings in the last 52 weeks of employment, or since the start of your last claim. The “Small Weeks” exclusion provision means that earnings in some or all small weeks (a calendar week for which the worker earned less than $225) can be ignored for the purpose of calculating the benefit rate. You can mail or bring this form to your local Service Canada Centre. Please ensure that you have answered all the questions, and to date and sign the form.
GroupEmployment Insurance
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Service Canada (SC)

SMALL WEEKS QUESTIONNAIRE - QUESTIONNAIRE SUR LES PETITES SEMAINES
PDF: SC-INS5186, 190 KB, printed on 1 pages (8.5 x 11)

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