Form 1 Statutory Accident Benefit Schedule

Ontario Automobile Insurance Application for Accident Benefits







Instructions:


1 - Identity of Claimant

To be completed by person injured in automobile accident















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:





















3 - Details of Accident



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?













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:






Automobile Owner





















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?











Treating Physician




















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:


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










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

Other Employer (if any)










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 Weekly Income for Last 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.