5160 Yonge Street
Toronto ON M2N 6L9
Commission file number
Complete ALL sections.
Attach extra sheets if necessary.
Use this Application to intervene in an appeal before the Commission. You must serve a copy of this Application and any supporting submissions on all parties to the appeal. You must also file the Application and a Statement of Service with the Commission.
Any party to the appeal may support or object to this Application by filing written submissions with the Commission within 10 days of being served with the Application. The submissions must include the party’s reasons why the applicant should, or should not, be permitted to participate. You must serve a copy of the written submission on the representative of the person making the Application for Intervention, or, if not represented, on the person seeking to intervene. You must then file a Statement of Service with the Commission.
Personal information requested on this form is collected under the authority 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.
Appeal file number
Company name OR Last name
Home phone number
Work phone number
Work phone number Ext.
File reference number
Phone number Ext.
Lawyer - Law Society licence number
Licensed paralegal - Law Society licence number
Not required to be licensed
Not required to be licensed - Specify the type of exemption from the list of exemptions recognized
in the Law Society‘s by-laws
1. I seek to intervene in this appeal for the following reasons.
Extra sheets attached
2. I wish to make submissions on the following issues of law. (Include a reference to any statutory provision to be relied on.)
Extra sheets attached
I am relying on the following documents for the Application
Copies of documents are attached
I certify that all information in this Application for Intervention and attachments is true and complete. I realize that copies of all information filed with this Application for Intervention will be given to the other party in this dispute.
Name (please print)
Total number of extra sheets attached
1131E (2011/08) © Queen’s Printer for Ontario, 2011
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