Government of Ontario: Financial Services Commission of Ontario

Dispute Resolution Services

Response by Insurer to an Application for Arbitration – FORM E

An Application for Arbitration has been filed with the Dispute Resolution Services of the Financial Services Commission of Ontario (the "Commission"). A copy of the Application for Arbitration is attached. Your company is named as a party in this arbitration.

Use this form to respond to the issues raised in the Application. You can add new issues which have been mediated but not settled. You must complete all sections of the Response, serve a copy on the Applicant and provide proof of service to the Commission within 20 days of receiving this document.

Section 1

APPLICANT

Date of the motor vehicle accident



INSURANCE COMPANY

Contact person:







Phone number:

Fax number:

LEGAL REPRESENTATIVE







Work phone number:

Fax number:

The representative is:


      


      


      

TYPE OF HEARING

1.Does the insurer want an oral hearing?

2. Does the insurer require special service such as audio visual equipment?

    

3. Will the insurer be arranging for the services of a Court Reporter?

    

Section 2

ISSUES IN DISPUTE

Check the benefits that were not resolved in mediation and which the insurer now wants to respond to or now wants arbitrated. The insurer may add new issues which have been mediated at FSCO but not settled. For each benefit disputed, briefly explain the insurer’s position. (Attach OCF-9 and extra sheets if necessary.)

Which weekly benefit are you disputing?

What is being disputed?


$

Date of Insurer's refusal to pay:

Reason for refusal

$

What is being disputed?


Date of Insurer's refusal to pay:

Reason for refusal

$

Date of Insurer's refusal to pay:

Reason for refusal

$

Date of Insurer's refusal to pay:

Reason for refusal

$

Date of Insurer's refusal to pay:

Reason for refusal

$

Date of Insurer's refusal to pay:

Reason for refusal

$

Date of Insurer's refusal to pay:

Reason for refusal

$

Reason for refusal

What is being disputed?



$

$

$

$

$

Particulars:

Section 3

DOCUMENT LIST

This section MUST be completed      (Attach extra sheets if necessary)

It is expected that the Applicant and the Insurer have exchanged key documents prior to the filing of an Application for Arbitration.

Documents -1. List key documents in your possession which you will refer to in the mediation.

Identify the type of document (letter, medical report, tax return), the name of the writer or issuing institution and the date of the document.

Documents -2. List key documents not currently in your possession, which you intend to get from other sources (such as employers, doctors, Revenue Canada) for use in the arbitration. You should also include any documents requested from the other party (such as surveillance evidence, a summary of benefits paid) which have not yet been provided.

Wherever possible, identify the type of document (letter, medical report, tax return), the name of the writer or issuing institution and the date of the document.


Date:

Send the original and one copy of the completed application to Arbitration Services at the address noted below. Keep an additional copy of the completed application for yourself.

Mediation Services
Dispute Resolution Services
Financial Services Commission of Ontario
5160 Yonge Street, 14th Floor, Box 85
Toronto, ON  M2N 6L9

If you have any questions about this application, or want more information, contact: Mediation Inquiries In Toronto at: 416-590-7210 or Toll Free: 1-800-517-2332, ext. 7210 Fax: 416-590-7077 FSCO website: www.fsco.gov.on.ca