Government of Ontario: Financial Services Commission of Ontario

Dispute Resolution Services
5160 Yonge Street
Box 85
Toronto ON M2N 6L9

Reply by the Applicant for Arbitration Form G

Use this form to reply to any point made by the insurance company in its Response to your Application for Arbitration. You must reply to any new issues raised by the insurance company in their Response. If no new issues are raised by the insurance company, this Reply is op-tional. You must serve a copy of the Reply on the Insurance Company within 10 days of your receipt of the Response by the Insurer to your Application. You must also file the Reply and a Statement of Service with the Commission. Personal information requested on this form is collected under the au-thority of the Insurance Act, R.S.O. 1990, c. I.8, as amended. This information, including documents submitted with this form, will be used in the dispute resolution process for accident benefits. This information will be available to all parties to the proceeding. Any questions about this collection of information may be directed to the Director of Arbitrations, Dispute Resolution Services, FSCO.



The representative is:



SIGNATURE I certify that all information in this Reply and attachments is true and complete. I realize that copies of all information filed with this
Reply will be given to the other party in this dispute..