Form 1 Satutory Accident Benefit Schedule

Ontario Automobile Insurance Application for Accident Benefits











Instructions


1- Identity of Claimant

To be completed by person injured in automobile accident










Date of Birth:

















Area Code - Home Telephone Number


Area Code - Work Telephone Number


Language Preferred




What is the best way to reach you?







Between the hours of:



and





2 - Claimant’s Representative

To be completed only if the applicant is deceased, a minor or unable to file an application on his or her own or has retained a representative

Representing the Claimant as




-









Area Code - Work Telephone Number



Area Code - Fax Number










3 - Details of Accident

Date of Accident


Time of Accident


The Claimant was




To your knowledge did a Police Officer investigate accident?










Did the accident occur while you were in the course of your employment?



Was a claim filed with the Workers' Compensation Board or an agency outside Ontario responsible for compensating victims of work related accidents?















4 - Insurance Details or Automobile Information

Were you insured under any automobile insurance policy on the date of the accident?


Automobile Licence Plate Number Insurer Policy Number
1
2




You were:





You are claiming against:















Area Code - Home Telephone Number





Area Code - Work Telephone Number
































Automobile Type









Did you report this accident to any other insurer?





5 Claimant’s Medical Condition as a Result of Accident

Did you receive medical attention following the accident?

















































Were you unable to continue your work/studies/normal activities as a result of the accident?



If yes, from what date?

Have you returned to work/studies/normal activities?



If yes, when?

If Claimant died as a result of accident
Time of Death



6 Claimant’s Employment

At the time of the accident you were:









If unemployed, have you worked 180 days out of the last 12 months? If Yes, complete the employment section

Most Recent Employer







Area Code - Work Telephone Number




Area Code - Fax Number













Type of Employment















Income from Employment How are you paid?




Gross Weekly Income Last 4 Weeks Preceding Accident
Week 1 Week 2 Week 3 Week 4
Salary
Tips, Commissions
Other Monetary Compensation
Total


Gross Income for 52 Weeks Preceding Accident
Number of Weeks Worked Gross Income
Salary
Tips, Commissions
Other Monetary Compensation
Total

Other Employer (if any)







Area Code - Work Telephone Number




Area Code - Fax Number











Type of Employment

















Gross Weekly Income Last 4 Weeks Preceding Accident
Week 1 Week 2 Week 3 Week 4
Salary
Tips, Commissions
Other Monetary Compensation
Total


Gross Income for 52 Weeks Preceding Accident
Number of Weeks Worked Gross Income
Salary
Tips, Commissions
Other Monetary Compensation
Total

Are you insured under any other sick leave plan or income continuation benefit plan?






7 Declaration

An application for accident benefits must be signed by the claimant or the claimant’s representative where the claimant is a minor or is unable to sign. I certify in good faith that the information provided is true.







Date