Form 2 Satutory Accident Benefit Schedule

Ontario Automobile Insurance Application for Additional Accident Benefits










Date of Accident

Instructions


1- Identity of Claimant

To be completed by person injured in automobile accident or their representative










Date of Birth















2 - Claimant’s Expenses

Attach original receipts

Item Date Description of Service and Name of Service Provider Amount
Total Amount
$

3 - Claimant’s Dependants

To be completed when requesting Primary Caregiver Benefits

Are you the primary caregiver of a child under 16 or a person dependant on you because of physical or mental incapacity?



If yes, list the dependants who reside with you.

Name Date of Birth
Year-Month-Day


4 - Declaration by Claimant

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







Date