Form 3 Satutory Accident Benefit Schedule

Ontario Automobile Insurance Death and Funeral Payment Request










Date of Accident

Instructions


1- Identity of Deceased










Date of Birth:
















Date and Time of Death


Marital Status of Deceased







2 - Identity of Person Making Claim

Making Claim as






-







Area Code - Telephone Number




Area Code - Fax Number



















3 - Payment Requested







4 - Details of Expenses

Attach original receipts

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


5 - Deceasedís Dependents










Date of Birth
















Area Code - Home Telephone Number


Area Code - Work Telephone Number


Language Preferred














Date of Birth
















Area Code - Home Telephone Number


Area Code - Work Telephone Number


Language Preferred














Date of Birth
















Area Code Home - Telephone Number


Area Code Work -Telephone Number


Language Preferred





Is there any other person who may be entitled to make a claim for these benefits?






6 - Declaration

I certify in good faith that the information provided is true.







Date