Form 2 Statutory Accident Benefit Schedule

Ontario Automobile Insurance Application for Additional Accident Benefits








Instructions:


1 - Identity of Claimant

To be completed by person injured in automobile accident













2 - Claimant’s Expenses

Attach original receipts:

Claimant's Expenses
Item Date Description of Service and Name of Service Provider 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.

Claimant's Dependant's
Name Date of Birth
yyyy-mm-dd)


4 - Declaration of 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.