Government of Ontario: Financial Services Commission of Ontario

Dispute Resolution Services

Statement of Service Form F

The purpose of this statement is to verify that a copy of a document was delivered to a party. A Statement of Service must be
completed for every document served and given to the insured person and the insurance company, or their representatives. Do not
use this form where proof of service of a Summons to Witness and payment is required to be filed with the Commission
. In
this case, you should use an Affidavit of Service for Summons to Witness which is available at the Commission.

Case Information

Who are you?

Who was served?

What was served?

Arbitration Documents

Appeal Documents

How was it served?

A copy of the fax transmission record, or the courier or postal receipt may be required as
evidence to support this Statement.

Your Signature