Form 3 Statutory Accident Benefit Schedule

Ontario Automobile Insurance Death and Funeral Payment Request

Insurer Information








Instructions:


1 - Identity of Deceased















Marital Status of Deceased:







2 - Identity of Person Making Claim

Making Claim as:























3 - Payment Requested






4 - Details of Expenses

Attach original receipts

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

5 - Deceasedís Dependents














Language Preferred:




















Language Preferred:






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


If yes, please specify:

6 - Declaration

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