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Pandemic Pay Attestation

The Ontario government has defined the rules under which eligible employees qualify for the $250 lump sum pandemic payment.

Where an Eligible Worker works at least one hundred (100) hours of eligible work per 4-week period, $250 lump sum will be paid. It can be over 100 hours worked with multiple employers, but only one lump sum per 4-week period is paid. The lump sum is paid by the primary employer.

Where the 100 hours are split across two or more employers, the employee will provide an attestation to the primary employer of the other hours worked.

If you work for multiple employers and you have identified Acclaim Health as your Primary Employer, please complete the attestation below.

NOTE: If you have multiple other employers, please submit one form per employer.



  • Contact Information

  • Other Employer Information

  • Attestation

  • MM slash DD slash YYYY
  • Permission to Submit

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