To be completed by person injured in automobile accident
What is the best way to reach you?
Between the hours of:
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:
The Claimant was:
To your knowledge did a Police Officer investigate accident?
If yes, name of Police Force Detachment or Division:
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?
Were you insured under any automobile insurance policy on the date of the accident?
You are claiming against:
Did you report this accident to any other insurer?
Did you receive medical attention following the accident?
Were you unable to continue your work/studies/normal activities as
a result of the accident?
Have you returned to work/studies/normal activities?
If Claimant died as a result of accident, state time of death:
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.
Type of Employment
How are you paid?
Are you insured under any other sick leave plan or income continuation benefit
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.