Government of Ontario

Financial Services Commission of Ontario
5160 Yonge Street
Box 85
Toronto ON  M2N 6L9

Dispute Resolution Services

Application for Intervention
Form K

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 CASE



APPLICANT

     












APPLICANT’S REPRESENTATIVE

     











The representative is:

   
   

      

SUBMISSIONS






Documents



SIGNATURE AND CERTIFICATION

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.