To be completed by person injured in automobile accident
Attach original receipts:
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.
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.