Government of Ontario: Financial Services Commission of Ontario

Guide For Completing Dispute Resolution Services (DRS) Forms

Application for Variation/Revocation – FORM L

Use this form to apply for a Variation or Revocation of an Arbitration or an Appeal decision.

An Application for Variation/Revocation, instead of a Notice of Appeal, is appropriate if the circumstances of the insured person have changed significantly since the hearing, new evidence not available at the arbitration hearing or the appeal, has become available, or there is some clear error in the order (for example, the order does not correspond to the reasons for the decision).

After completing your Application for Variation/Revocation form, you must file one copy with the Financial Services Commission of Ontario (the “Commission”) at the address below. The steps you must take are set out in this form.

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 application, 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, at the address below

If you have any questions or want more information, contact:

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

In Toronto at: 416-590-7222

Toll Free: 1-800-517-2332, ext. 7222

Fax: 416-590-7077

Commission website:

Applying for Variation or Revocation of an Arbitration order or an order of an Appeal Decision

For a complete set of the rules for variations/revocations, see the Dispute Resolution Practice Code.

Step 1

Complete this Application for Variation/Revocation form. If it is incomplete, it may be rejected. After completing the form, you must serve a copy on the respondent (the other party). If the respondent was represented by a lawyer, you should serve the Application for Variation/Revocation on the lawyer. If not, serve the respondent.

Service may be done by personal delivery, courier, fax, regular mail, registered mail or any other method allowed by the Dispute Resolution Practice Code.

Then file the following with the Commission:

Step 2

Upon receiving a properly completed Application for Variation/Revocation, Statement of Service and the application filing fee, the Commission will promptly acknowledge the Application.

Step 3

To oppose your Application, the respondent must file a Response to Application for Variation/Revocation within 20 days of receiving acknowledgement of the Application for Variation/Revocation from the Commission. You will get a copy of the Response to Variation/Revocation from the respondent.

Step 4

Unless the Director of Arbitrations or an adjudicator delegated by the Director (known as Director’s Delegate) advises you differently, your written submissions must be served on the respondent and filed with the Commission within 30 days of the date the Response to Variation/Revocation was due. If a transcript is ordered, this time limit is extended to 30 days from receipt of the transcript.

Step 5

The Director or Director’s Delegate may decide the Variation/Revocation with or without a hearing.

How to Complete the Application for Variation/Revocation


Decision Details

This information can be found in the arbitration or appeal decision.

Applicant’s Name and Address

Fill your name and address as the person or insurance company making this Application for Variation or Revocation. Provide any alternative addresses, phone numbers, fax numbers or electronic mail addresses that will make It easier for us to contact you.

Applicant’s Representative

You may choose to have someone represent you. Although many people are represented by a lawyer in these proceedings, a lawyer is not required. If you have a representative, fill in the name, address and phone number of your representative. If it is a firm, please give the name of the firm in the box provided. A minor (a person under the age of 18) or a person who has been declared mentally incapable, must have a representative.

Reasons for the Application

Briefly state what part(s) of the Arbitration or Appeal decision you want varied or revoked and the reasons for your request. Attach extra sheets if necessary. Your Application for Variation/Revocation must be sufficiently detailed to allow the other party to respond. It is not necessary, however, for you to file your complete written submissions until later.

Action Sought

Briefly state the remedy or outcome you are seeking in your Application for Variation/Revocation.


Indicate if the hearing was recorded by a reporting service. If it was recorded, indicate if you have ordered a transcript of the hearing. If you do not intend to order a transcript, you must state why a transcript is not needed for the Application.


If you want to rely on any additional or new evidence in your Application for Variation or Revocation, you must identify the new evidence and explain why it should be allowed. This should include whether the evidence could have been presented at the hearing and whether it would have led the adjudicator to a different decision.

The Director’s Delegate will have access to the Arbitration exhibits and, therefore, it is not necessary to refile them.

This issue may be decided without further submissions so your explanation should be as detailed as possible.

Preliminary or Interim Order of an Adjudicator

The usual rule is that a party may not apply to vary or revoke a preliminary or interim order of an adjudicator. If you are seeking to vary of revoke an interim or preliminary order, you must explain why the usual rule should not apply.

It is likely that this issue will be decided without further submissions, so your reasons should be as complete as possible.


Sign the form and return it to the Appeals Unit at the Commission.


If you are an insured person, be sure to enclose the filing fee of $250 by cheque or money order made out to the MINISTER OF FINANCE. The Application will be rejected if the filing fee is not enclosed.

If you are an insurer, the Commission will invoice your company for the filing fee ($250) and the insurer assessment ($500).


Note: You may settle your dispute with the respondent directly at any time during the appeal process.

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