Accident Claim#002373921 Stephen Forde OCB1 Form

5600 CANCROSS COURT
MISSISSAUGA ON L5R 3E9
STEPHEN FORDE
125 COLE RD UNIT 21
GUELPH ON N1G 4S8
sforde69@yahoo.ca
December 6, 2023
Auto Policy No.: 4000729543

Claim No.: 002373921
Date of Loss: November 6, 2023
How to Apply for Accident Benefits
We understand that you were injured in the accident that occurred on November 6, 2023. Please find
the attached Application Package to assist you, if necessary, in applying for benefits that may be
available to you under the Statutory Accident Benefits Schedule (SABS).
If you intend to apply for benefits under the SABS, please notify us within 7 days. This is important as
a failure to notify us may impact your entitlement to the benefit.
If you will not be making an accident benefits claim, the enclosed forms do not need to be returned to
us.
Understanding the Claims Process

The enclosed coverage summary outlines the benefits you may be eligible for under the SABS.
Most of the claim forms will require your signature. To prevent the unauthorized use of your
signature throughout the claims process, we recommend that you do not sign blank forms. This will
ensure that you remain aware of any recommendations that are made in response to the injuries
associated with your claim.
We will contact you after we receive your completed Application for Accident Benefits Form (OCF-1).
Before beginning any medical or rehabilitation program, contact us as some expenses require pre-
approval.
To avoid any delays, please include your name and claim number on any future correspondence.
If you have any questions, contact me at kaitlin_mitchell@cooperators.ca or 1-905-434-4042.
Sincerely,
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Home, auto, commercial and farm insurance is underwritten by Co-operators General Insurance Company. Please refer to your policy for applicable coverage limitations and exclusions. Co-operators General Insurance
Company is committed to protecting the privacy, confidentiality, accuracy and security of the personal information that we collect, use, retain and disclose in the course of conducting our business. Please visit
www.cooperators.ca/privacy for more information. Co-operators® is a registered trademark of The Co-operators Group Limited. © 2021 Co-operators General Insurance Company.
Kaitlin Mitchell, Claims Representative I -Accident Benefits
Co-operators General Insurance Company
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Home, auto, commercial and farm insurance is underwritten by Co-operators General Insurance Company. Please refer to your policy for applicable coverage limitations and exclusions. Co-operators General Insurance
Company is committed to protecting the privacy, confidentiality, accuracy and security of the personal information that we collect, use, retain and disclose in the course of conducting our business. Please visit
www.cooperators.ca/privacy for more information. Co-operators® is a registered trademark of The Co-operators Group Limited. © 2021 Co-operators General Insurance Company.
ONTARIO – ACCIDENT BENEFITS
Coverage Summary – Policies Issued on or after June 1, 2016
What are Accident Benefits?

• Sometimes referred to as “no-fault benefits”, these benefits assist clients injured in auto
accidents regardless of fault.
• Covers out of pocket medical and rehabilitation expenses that are reasonable and necessary.
• Depending upon your circumstances, you may also qualify for a weekly benefit.
• The attendant care benefit provides limited coverage for incurred expenses if you are unable to
care for yourself following the accident.
Accident Benefits Application Package

• The Accident Benefits Application Package is enclosed for your use. If you intend to make a
claim, please return the completed Application for Accident Benefits (OCF-1) to me within 30
days. This completed form is required in order to pay benefits under the policy.
• The Package contains several other forms, as follows:
o Employer’s Confirmation of Income (OCF-2) – related to Income Replacement Benefits.
o Disability Certificate (OCF-3) – used in relation to claims for Weekly Benefits and
Housekeeping & Home Maintenance benefits.
o Permission to Disclose Health Information (OCF-5) – consent form which allows us to
request medical information necessary to determine your eligibility for benefits.
o Treatment Confirmation Form (OCF-23) – used to claim pre-approved treatment under
the Minor Injury Guideline.
• If you do not intend to make a claim for Accident Benefits, you do not have to return any
forms.
Where do I send the Completed Forms?

• There are rules in Ontario for determining which insurance company will be responsible for
paying an individual’s Accident Benefits claim. For instance, these rules indicate that the
insurance company where the person is a named insured or spouse/dependent of a named
insured would be required to pay instead of the insurance company where the person was a
passenger or involved in an accident with another vehicle.
• You can submit your completed forms to us or to any policy where you are an insured person.
The first insurer to receive the completed OCF-1 will handle your claim.
• If we receive your OCF-1 and we believe there may be a “higher priority” insurer that should be
responsible for paying your claim then we will investigate further and put the other insurer(s) on
notice for dispute. We will continue to handle your claim pending the outcome of the dispute.
Page 1 of 4
What Medical Expenses are Covered? How do I Claim?
• Goods and services recommended by a Health Practitioner (for example, a doctor or
physiotherapist) that are reasonable and necessary for your treatment and recovery (for
instance, physical therapy, medications, dental, etc.).
• Goods and services generally require prior approval from your insurer unless you are being
treated within the Minor Injury Guideline.
• Your health practitioner may submit a Treatment Confirmation Form (OCF-23) for pre-approved
treatment within the Minor Injury Guideline, or they may submit a Treatment and Assessment
Plan (OCF-18) for other goods and services. Your health practitioner should review their
recommendations with you and you will need to sign indicating your consent for their
submission. We recommend that you do not sign blank forms.
• The Statutory Accident Benefits Schedule considers other benefits to be primary. Your expenses
must be submitted first to any extended health benefits you have available. We will cover the
portion of approved expenses not otherwise covered by other benefit plans.
What is the Minor Injury Guideline?
• The Minor Injury Guideline allows for up to $2,200 of pre-approved treatment if you have
suffered a “minor injury”.
• Minor Injury means one or more of a sprain, strain, whiplash associated disorder, contusion,
abrasion, laceration or subluxation and includes any clinically associated sequelae (a condition
occurring as a result of another condition or event) to such an injury.
• An overall limit of $3,500 will apply if you suffer a predominantly minor injury and there is no
compelling evidence of a pre-existing medical condition that was documented by a health
practitioner before the accident and that will prevent you from achieving maximal recovery if
subject to the $3,500 limit or if limited to the goods and services authorized under the Minor
Injury Guideline.
• There is no coverage for attendant care benefits or in-home assessments if you have sustained a
minor injury.
What Limits Apply to the Medical, Rehabilitation and Attendant Care Benefits?
Type of Injury Sustained Medical, Rehabilitation and Attendant Care Benefits
Minor Injury $3,500 limit for Medical and Rehabilitation (5 year time limit);
$0 payable for Attendant Care
Non-Catastrophic Injury $65,000 combined limit (5 year time limit)
Catastrophic Injury $1,000,000 combined limit (no time limit)
If you are covered by optional medical, rehabilitation and/or attendant care benefits, additional
coverage above the standard benefits may be available.
Page 2 of 4
What are Weekly Benefits?
• There are 3 types of weekly benefit – Income Replacement Benefit (IRB), Non-Earner Benefit
(NEB) and Caregiver Benefit (CGB).
• Income Replacement Benefit (IRB):
o Compensates for lost income if you are substantially unable to perform the essential
tasks of your job.
o Applies if you were employed or self-employed on the date of the accident; or if you are
16 or older and worked at least 26 of the 52 weeks prior to the accident or you were
receiving Employment Insurance benefits on the date of the accident.
o Covers 70% of your gross pre-accident income, to a maximum of $400/week (unless you
purchased an optional IRB prior to the accident).
o Collateral benefits (i.e. short-term disability) and subsequent income are deductible.
o There is no payment for the first week of disability.
• Non-Earner Benefit (NEB):
o Compensates if you are completely unable to carry on a normal life and do not qualify
for an IRB. The benefit is also available if you were employed or self-employed and you
were a full-time student or a recent graduate.
o $185 per week.
o There is no payment for the first 4 weeks, or for more than 104 weeks after the
accident. The benefit is not payable before the insured person turns 18 years old.
• Caregiver Benefit (CGB):
o This benefit is only available if you sustained a catastrophic impairment or as an
optional benefit.
o Compensates for additional expenses incurred if you are the main caregiver of a child
under 16 or other person residing with you who needs care and you are substantially
unable to continue to provide that care as a result of the accident.
o Covers expenses up to $250/week, plus $50/week for each additional person in need of
care.
How do I Claim a Weekly Benefit?

• The Application for Accident Benefits (OCF-1) is your application. The Disability Certificate
(OCF-3) should be submitted with your Application as it will assist us in determining if you meet
the test of disability.
• Please complete Parts 1-4 of the Disability Certificate (OCF-3) yourself, then provide to your
Health Practitioner (i.e. doctor) to complete the balance.
• If you are claiming an Income Replacement Benefit then we will require information to allow us
to calculate your benefit. Please complete Parts 1-3 of the Employer’s Confirmation of Income
(OCF-2) form and provide it to your employer(s) to fill in the remainder.
Page 3 of 4
• If you qualify for more than one of these weekly benefits then you will need to elect which
benefit you wish to claim using the Election of Income Replacement, Non-Earner or Caregiver
Benefits (OCF-10) form.
What Other Benefits are Available?

• Expenses of Visitors provides limited coverage for expenses of certain family members who visit
you during your treatment or recovery.
• Lost Educational Expenses – up to $15,000 in incurred expenses if you were enrolled in school
and you are unable to continue the program as a result of the accident.
• Repair or replace items lost or damaged such as clothing, prescription eyewear, dentures,
hearing aids, prostheses or other medical or dental devices.
• Reasonable cost of examinations – these costs come out of your medical and rehabilitation
benefits limit.
• Housekeeping and home maintenance may be available if you sustained a catastrophic
impairment or if the optional benefit is applicable to you.
• Death and Funeral benefits.
Optional Benefits
• Optional benefits provide additional coverage. They must be purchased before the accident.
• The optional benefits are: Increased Income Replacement; Caregiver, Housekeeping and Home
Maintenance; Dependant Care; Increased Medical, Rehabilitation and Attendant Care; Optional
Catastrophic Benefit; Increased Death and Funeral; and Optional Indexation Benefit.
What if I have Questions?

• Please contact your Accident Benefits Claims Representative. They will be happy to answer your
questions and to assist you in any way they can.
Co-operators and Your Privacy

• Co-operators is committed to protecting the privacy, confidentiality, accuracy and security of
the personal information that it collects, uses, retains and discloses in the course of conducting
business.
This document provides a brief summary only and does not specify all of the rights and limitations set
out in the Statutory Accident Benefits Schedule (SABS). If there is a difference between the
interpretation of the wording in this document and the wording in the SABS then the SABS prevails.
Page 4 of 4
Accident Benefits
Application
Package
Use this package to apply for benefits if you were injured in an
automobile accident on or after November 1, 1996.
About this Application for Accident Benefits

Please note that all automobile accidents involving bodily injury must be reported to the police. Claims for
certain accident benefits must be made within 7 days. Please contact your adjuster for further information.
There are five forms in this package:
■ Application for Accident Benefits (OCF-1)
Fill out this form when you are applying for benefits for the first time as a result of an accident,
including if you are injured and are applying for income replacement benefits. You may be eligible for
weekly benefits even if you were unemployed or retired at the time of the accident.
This Application for Accident Benefits form must be returned within 30 days after receiving the package.
If you are unable to return it within 30 days, submit it to your insurance company anyway and explain
why you were not able to complete it within 30 days. Return the original form to the insurance company
and make a copy for your records.
■ Employer’s Confirmation of Income (OCF-2)
If the insurance company asks you to, please give this form to your employer. This form is completed
by you or your representative and by your employer. If you had more than one employer during the
past 52 weeks, it is necessary for each employer to complete a separate form. Your insurance company
may ask for other proof of income.
■ Disability Certificate (OCF-3)
If the insurance company asks you to, please fill out the first section and give this form to your health
practitioner (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician,
physiotherapist, speech-language pathologist or psychologist). This form is completed by you or your
representative and by your health practitioner.
■ Permission to Disclose Health Information (OCF-5)
If the insurance company asks you to, please complete this form. The insurance company requires
your medical information in order to correctly determine your eligibility for benefits. Health
professionals require your written permission to disclose this information to the insurance company.
■ Treatment Confirmation Form (OCF-23)
This form must be completed to confirm treatment received under the Minor Injury Guideline for
accidents that occurred on or after September 1, 2010. There are exceptions. Please contact your
insurance company to find out if this form is required.
After the insurance company reviews your complete application package, you will be contacted about the
benefits you are entitled to receive. If your insurance company needs any additional information in order to
process your application, they will contact you.
Warning – Offences
It is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer in connection
with the person’s entitlement to a benefit under contract of insurance. The offence is punishable on conviction by a maximum fine of
$250,000 for the first offence and a maximum fine of $500,000 for any subsequent conviction.
It is an offence under the federal Criminal Code for anyone to knowingly make or use a false document with the intent it be acted on as
genuine and the offence is punishable, on conviction, by a maximum of 10 years imprisonment.
It is an offence under the federal Criminal Code for anyone, by deceit, falsehood or other dishonest act, to defraud or to attempt to
defraud an insurance company. The offence is punishable, on conviction, by a maximum of 14 years imprisonment for fraud involving
an amount over $5,000 or otherwise a maximum of 2 years imprisonment.
Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

FSCO 1224E.5 Page 1 of 8
Where do I send the Application Forms?
Please follow the instructions below.
1. If You Own, Lease, or Have Regular Use of a Company Automobile
As of the date of the accident did you, your spouse or someone you are dependent on (please check all the
options that apply to you):
Own an automobile?
Lease or have a contract to rent an automobile for more than 30 days?
Drive a company automobile which was made available for your regular use?
Yes - If you checked only one, send the forms to the insurance No - If none apply, continue to 2.
company that insures this automobile.
Yes - If you checked more than one, send the forms to the
insurance company of the vehicle in which you were an
occupant at the time of the accident.
Yes - If you checked more than one and were not an occupant
in either of the automobiles, send the forms to the insurer
of either vehicle (you choose).
2. If You are a Listed Driver

Are you listed as a driver on somebody’s insurance policy?
Yes - If yes, send your forms to the insurance company that x No - If no, continue to 3.
issued the policy you are listed on.
The following categories only apply if:

• You, your spouse or someone you are dependent upon does not own, lease, or regularly use
a company automobile.
• You are not listed as a driver on a policy.
3. Occupant of Somebody Else’s Automobile

Were you an occupant of somebody else's automobile that was insured at the time of the accident?
Yes - If yes, send your forms to the insurance company that No - If no, continue to 4.
insures this automobile.
4. Pedestrian or Bicyclist
Were you a pedestrian or a bicyclist struck by an automobile that was insured at the time of the accident?
x Yes - If yes, send your forms to the insurance company of No - If no, continue to 5.
the automobile that struck you.
5. Uninsured Automobile
Were you an occupant of an automobile that was not insured at the time of the accident?
Yes - If yes, send your forms to the insurance company of any No - If no, continue to 6.
other automobile that was involved in the accident.
6. None of the Above Apply

If you do not have automobile insurance and no other automobile involved in the accident has automobile insurance or can
be identified, you may be entitled to accident benefits from the Motor Vehicle Accident Claims Fund. Please complete the
entire application package and see Part 10.

Return this form to:
Application for Accident
Benefits (OCF-1)
Use this form for accidents that occur on or after November 1, 1996.
Claim Number: 002373921

Policy Number: 4000729543
Date of Accident:
(YYYYMMDD) 2023-11-06
A separate form must be completed for each person who is applying for accident benefits. Completion of ALL sections is mandatory. Your
application may be denied if information is incomplete or incorrect. Please print clearly.
Part 1 Last Name First Name and Initial Gender Marital Status
Applicant Stephen Forde Male Female

Single Separated
Driver’s Licence Number Birth Date Married Divorced
Information Year Month Day
Common-law Widow(er)
1974-03-01
Address Is anyone dependent on you for
financial support or care?
21-12 Cole Rd.
City Province Postal Code Yes, how many persons?
Guelph ON N1G4S8 No
Home Telephone Work Telephone Fax Number
(226) 505-7361
You can be reached: Language Spoken: What is the best time to reach you:
by telephone at home English Day(s) of the week ALL
by personal visit at work E-mail: Time of day 10 a.m.
other emal sforde69@yahoo.ca 5 p.m.
Part 2 Complete this section only if the applicant injured in the accident is deceased, is a minor, is unable to fill out the form on
Applicant’s their own, or has retained you as their representative.
Last Name Relationship with applicant
Representative
Parent Guardian
(if applicable) First Name and Initial Lawyer Other
Other Paid Representative
Address
City Province Postal Code
Work Telephone Fax Number E-mail:
Part 3 Date of Year Month Day Time of a.m. Driver Pedestrian

Accident
2023-11-06 Accident 7:15 p.m. You were a: Passenger Other cyclist
Accident
Accident Location: Hwy. No./Street Name City Province
Details and
Edinburgh/Municipal Guelph ON
Health
Information Did the accident occur while you were at work? Yes No
Did you file a claim with the Workplace Safety and Insurance Board? Yes No
Was the accident reported to the police? Yes (Give details below) No
Officer Name Badge No. Date accident Year Month Day

Mathew GU13 reported to the police 2023-11-06
Police Department/Collision Reporting Centre
GPS
Were you charged? No Yes (Give details)
Improper rear light only reflector
Give a brief description of the accident. If you suffered any injuries as a result of the accident, describe the cause and extent of the injuries.
I was struck from behind
Were you able to return to your normal activities following the accident? Yes No
Did you go to the hospital? Yes (Give details) No
Did you go to see a health professional? (for example: physician, chiropractor, physiotherapist?) Yes (Give details) No
physiotherapy
Additional sheets attached

Part 3 Name of Health Professional Name of Facility
Motion Physio
Accident
Address
Details and Harvard Road University Plaza
Health City Province Postal Code
Information Gueph ON
(cont’d)
Has this Health Professional begun any treatment? Yes (provide details) No
Part 4 In order to determine which automobile insurer is responsible for paying benefits, it is necessary to know whether you have
your own policy or whether you are covered by somebody else's insurance policy. To help make that determination, please
Details of
complete the following:
Automobile
Insurance A Are you covered under any of the following automobile insurance policies?
Your own policy Yes No
Your spouse's policy Yes No
The policy of any person on whom you are dependent (e.g., a parent) Yes No
A policy that lists you as a driver (e.g., a friend) Yes No
Your employer's policy (e.g., company car) or spouse's employer's policy Yes No
A policy insuring long-term rental cars (for rentals exceeding 30 days) Yes No
If you answered “No" to all of the above, go to B . If you answered "Yes" to any of the above, complete the following:
Name of Policyholder
Insurance Company Policy Number
Automobile – Make, Model, Year Licence Plate Number
Were you an occupant of this automobile at the time of the accident? Yes No
If you answered “Yes” to more than one box in this part, provide additional insurance details below.
Name of Policyholder
Were you an occupant of this automobile at the time of the accident? Yes No
B If you checked "No" to all of the boxes in A you must send your application to the insurer of the automobile that you
occupied at the time of the accident, or the vehicle that struck you if you were a pedestrian or bicyclist. If this automobile
was not insured or was unidentified, describe any other vehicle involved in the accident. Provide details below.
The policy you are claiming under insures: Vehicle type covered by this policy:
The vehicle I was riding in at the time of the accident Passenger Truck
The vehicle that struck me as a pedestrian/bicyclist Motorcycle Bus
Another vehicle that was involved in the accident Taxi/Limousine Snowmobile
Other
Owner of the Vehicle Home Telephone
Address Work Telephone
Name of Policyholder Driver’s Licence Number
Did you report the accident to any other insurance company? Yes (provide details) No
Insurance Company Type of Insurance

Part 5 Which of the following describes your status at the time of the accident?
Applicant Employed Not Employed
Status Employed and working Unemployed
Student or recent graduate
Self-Employed Unemployed and,
have worked 26 weeks in the past 52 weeks
receiving Employment Insurance Benefits
Retired Caregiver
Part 6 Were you attending school on a full-time basis at the time of accident or had you completed your education less
than one year before the accident?
Student
Yes (Give details below) No (Continue to Part 7)
Attending
School Name of School Year Month Day
Date Last Attended
Address Program and Level
City Province Postal Code Projected Date for Year Month Day
Completion of Studies
Year Month Day

Are you now attending school? Yes (Enter date) No
| | | | | | |
Year Month Day
Were you able to return to school after the accident? Yes (Enter date) No
| | | | | | |
Part 7 Were you the main caregiver to people living with you, at the time of the accident?
Caregiver Yes (Complete information below) No (Continue to part 8)
Were you paid to provide care to these people? Yes (Continue to part 8) No
List the people who you were caring for at the time of the accident
Date of Birth Disabled
Name
Year Month Day Yes No

Did your injuries prevent you from performing the caregiving activities you did prior to the accident?
Yes (Explain below) From what date? Year Month Day

No
Explanation:
At any period since the accident, were you able to return to caregiving?
Year Month Day
Yes (From what date?) No

Part 8 Give details of your employment for the past 52 weeks. Start with your current or most recent employer. If you held more
than one position with the same employer, use a separate line for each position. Gross income is before taxes and
Income
deductions.
Replacement
Determination If you were self-employed during the 4 weeks prior to the accident, please consider yourself the employer for the
purpose of completing this section.
Date Name and Address Position/Essential No. of Hours Gross Income
Year/Month/Day of Most Recent Employer Tasks Per week for the period
From: $
To:
From: $
To:
From: $
To:
From: $
To:

Did your injuries prevent you from working?
Year Month Day
Yes (From what date?) No (Continue to Part 9)
At any period since the accident, were you able to return to work since the accident?
Yes Year Month Day
No
(From what date?)
The amount of your benefit is based on your past income. During which of the following periods did you have the highest average weekly
income?
Last 4 weeks (not applicable for self-employed persons)
Last 52 weeks
Last fiscal year (self-employed only)
Part 9 Do you, your spouse or anyone you are dependent on (e.g., parents) have any other benefit plan that covers you (e.g., group
or private, union, disability, medical or dental, etc.)?
Other
Insurance or
Yes (Give details below) No
Collateral
Payments Name of Benefit Payor Type of Coverage Policy or Certificate Number
During the past 52 weeks, did you receive any income from a disability plan? Yes (Enter dates) x No
Year Month Day Year Month Day

From: To: Total Amount
Received
$
Are you receiving Employment Insurance Benefits? Yes (Enter date) x No
Year Month Day Year Month Day
From: To: Total Amount
Received
$
Are you receiving Social Assistance Benefits (welfare)? x Yes No

Part 10 DO NOT FILL OUT UNLESS ITEMS (1) TO (5) ON PAGE 2 DO NOT APPLY AND YOU ARE APPLYING TO THE MOTOR
VEHICLE ACCIDENT CLAIMS FUND
Motor Vehicle
Accident You and your representative acknowledge that you have the responsibility to investigate and apply to all potential insurers to
Claims Fund which the applicant may have recourse BEFORE submitting an application to the Motor Vehicle Accident Claims Fund
(MVACF) at 5160 Yonge Street, P.O. Box 85, Toronto, ON M2N 6L9. If you have any questions about your MVACF
application contact: MVACF in Toronto at (416) 250-1422 or Toll Free at 1-(800) 268-7188.
You and your representative acknowledge that the application MUST INCLUDE a completed:
NOTICE OF COLLECTION OF PERSONAL INFORMATION FORM, signed and attached*
Form 3 – Section 6 MVACF Application for Statutory Accident Benefits, signed and attached*
Motor Vehicle Accident (Police) Report, attached.
before the applicant can make an application for the payment of accident benefits from the MVACF.
(* These forms are available at www.fsco.gov.on.ca)
I certify that I have read this part and understand that this application for accident benefits is not complete until the required
forms are completed, signed and provided to the MVACF.
Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date
(YYYYMMDD)
Part 11
Direct I direct the insurer, including the Motor Vehicle Accident Claims Fund, to pay the licensed service provider directly for
Payment that portion of the approved goods and services specified on any Treatment Confirmation Form (OCF-23) and/or Treatment
Assignment by and Assessment Plan (OCF-18) that are not covered by extended/supplementary health insurance.
Applicant Applicants that have extended/supplementary health insurance responding to a claim may need to provide payment out of
pocket before the extended/supplementary health insurer reimburses the claimant.
(only applicable to
applicants obtaining
treatment/services
Applicant Initials
from a licensed
service provider) SF

Part 12 TO THE INSURER, INCLUDING MVACF, TO WHOM THIS APPLICATION IS BEING SUBMITTED:
Signature I UNDERSTAND that you, and persons acting for you, will collect personal information and personal health information about
me that is related to my claims for accident benefits arising out of the accident described in this application, and that all such
information will be collected directly from me or from any other person with my consent.
I ALSO UNDERSTAND that you and persons acting for you will collect information about my driving record, automobile
insurance policy history and automobile insurance claims history if they exist.
I ALSO UNDERSTAND that if I am the holder of an automobile insurance policy, you, and persons acting for you, will collect
the driving record, automobile insurance policy history and automobile insurance claims history of any listed drivers on my
automobile insurance policy or other drivers whom I have permitted to drive my automobile.
I ALSO UNDERSTAND that the information described above will be collected and used only as reasonably necessary for the
purposes of:
 Investigating my claims and processing my claims as required by law, including the Ontario Automobile Policy;
 Obtaining or verifying information relating to my claims in order to determine entitlement and the proper amount of
payment;
 Recovering payment from insurers and others liable in law for amounts that you pay in connection with my claims;
 Identifying and analyzing the nature and costs of goods and services that are provided to automobile accident victims
by health care providers;
 Preventing, detecting and suppressing fraud;
 Compiling anonymized statistics for government agencies; and
 Assessing underwriting risks and claims experience.
I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons or
organizations, who may collect and use this information only as reasonably necessary to enable you or them to carry out the
purposes described above:
Insurers; insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants;
financial advisors; solicitors; organizations that consolidate claims and underwriting information for the insurance
industry; fraud prevention organizations; other insurance companies; the police; databases or registers used by the
insurance industry to analyze and check information provided against existing information; and my agents or
representatives as designated by me from time to time.
I ALSO UNDERSTAND that you, and persons acting for you, may pool this information with information from other sources
and may analyze this information for the limited purpose of preventing, detecting or suppressing fraud.
I CONSENT and, if I am the holder of an automobile insurance policy, declare that I have obtained consent from the listed
drivers on my policy and any other drivers whom I have permited to drive my automobile, to you collecting, using and
disclosing this information in the manner described above, but no more of such information than is reasonably necessary to
meet the legitimate purpose of such collection, use or disclosure.
I UNDERSTAND that if I have any questions about this consent I am free to consult with my insurance company
representative or legal advisor before signing this document.
I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose this information to
others without my knowledge or consent.
I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.
I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading
statement or representation to an insurer under a contract of insurance.
I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone, by deceit,
falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for
processing payments of claims; identifying and analysing the nature, effects and costs of goods and services that are
provided to automobile accident victims, by health care providers; and PREVENTING, DETECTING AND SUPPRESSING
FRAUD.
To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please
visit http://www.ibc.ca/en/privacy-terminology.asp
Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (YYYYMMDD)
Stephen Forde 2023/12/17

Employer's Confirmation Form
(OCF-2)
Date of Accident:
(YYYYMMDD) 2023-11-06
If your insurance company asks you to complete this form, fill in parts 1 through 3 and give the form to your employer or former
employer(s) to complete the rest. Please have each employer you listed on your Application for Accident Benefits form fill out a
separate form. Extra forms are available from your insurance company. Your employer(s) will return the form(s) directly to the insurance
company. Please print clearly.
Part 1 Last Name First Name and Initial Gender

Applicant Male Female
Information Address
Birth Date (YYYYMMDD) Home Telephone Work Telephone
Name of Insurance Company
Address
Name of Policyholder Policy Number
Part 2 I authorize my employer to disclose to my insurance company or its authorized representative, any relevant information about my
Authorization employment, including copies of relevant documents directly relating to my application for income replacement benefits and
details of any collateral sources of income or benefits.
Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision maker Date (YYYYMMDD)
Part 3 Employed Self-Employed

What Salary To my employer or former employer: If you are or were self-employed at any time during the four
I was involved in an automobile accident on: weeks before the accident, please consider yourself the
Information is employer for the purpose of completing this form.
Needed (YYYYMMDD) I was self-employed four weeks before the accident and I
designate the following time period to be used to calculate my
income (check one  and proceed to part 4).
To process my application, my insurance company needs 52 weeks (YYYYMMDD)
information about my salary for the following period before the From
Last
date of the accident. (If you check  both, the insurance
complete
company will determine which period provides the highest
fiscal year (YYYYMMDD)
benefit.)
4 weeks To
52 weeks

FSCO (1003E.1) Page 1 of 3
The rest of this form must be completed by your employer or former employer.
Part 4 What was the applicant's actual gross income for the period before the accident date checked  above? If the employee worked
Applicant's only part of the period, list the gross income received from you during the period.
Income Gross Income Last 4 Weeks Before Accident
Gross Income for Last 52 Self-Employed:
Weeks Before Accident Gross Income
Week 1 Week 2 Week 3 Week 4 No. of Weeks Gross
additional Worked Income
sheets attached
Salary
Tips, Commissions
Other Monetary
Compensation
Total
Was the applicant absent from work for any time during the period checked () in Part 3?
Are there any other types of compensation available from the employer?
Part 5 To your knowledge, is the applicant eligible to receive the following benefits?
Other Benefits Income Continuation Benefit (short- Insurance Company Policy No.
term or long-term disability plan) No Yes
Supplementary Medical, Insurance Company Policy No.

Rehabilitation or Attendant Care No Yes
Benefits
Did applicant use sick credits following
Sick Leave No Yes No Yes
the auto accident?
Is the applicant a member of a union? No Yes

Does or did the applicant contribute to the Canada Pension Plan or a similar plan? No Yes
Was a claim filed with the Workplace Safety and Insurance Board as a result of this accident? No Yes
Part 6 Date of
(YYYYMMDD) (YYYYMMDD) Latest Job Title
From To
Employment Employment
Details (YYYYMMDD) (YYYYMMDD)
additional Last Date Worked: Date of Return to Work (if applicable)
sheets attached
Brief Job Description
Essential Tasks of Job (Attach physical demand analysis if available):
Type of Employment Full-Time Part-Time Casual Seasonal
Part 7 Company Name Contact Person

Employer
Information Address Tax Reg. # or Business Identification Number (BIN)
Telephone Number Fax Number

Part 8 I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.
Signature
I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement
or representation to an insurer under a contract of insurance. Regulated sectors may be subject to an examination or inquiry
about matters in connection with a licence and or unfair or deceptive act or practice. Non-compliance with applicable regulations
may result in enforcement actions ranging from an administrative monetary penalty to prosecution under the Provincial Offences
Act.
processing payments of claims; identifying and analysing the nature, effects and costs of goods and services that are provided to
automobile accident victims, by health care providers; and PREVENTING, DETECTING AND SUPPRESSING FRAUD.
Signature of Employer: Date (YYYYMMDD)
Employer Name: (Please print) Title

Disability Certificate
(OCF-3)
Date of Accident:
(YYYYMMDD) 2023-11-06
Use this form for accidents that occur on or after November 1, 1996. If your insurance company asks you to complete this form, fill out
Parts 1 to 3 and give the form to your health practitioner (chiropractor, dentist, nurse practitioner, occupational therapist,
optometrist, physician, physiotherapist, psychologist, speech language pathologist). After your health practitioner has explained
your accident-related injury to you, sign Part 4. Your health practitioner will complete the rest of the form, based on his/her most recent
assessment, and return it to the insurance company.
Only an authorized health practitioner can complete this form. The health practitioner’s opinion will be relied upon by people who review
the certificate to make important decisions. Accordingly, it is necessary to be accurate and complete. Please print clearly and provide
all information requested. This form may not be materially altered.
Confidentiality: Collection, use and disclosure of this information is subject to all applicable privacy legislation.
Part 1 Date Of Birth (YYYYMMDD) Gender Telephone Number Extension

Applicant Male Female - -
Information Last Name First Name
To be completed by
the applicant Middle Name E-mail (optional)
Address
Year Month Day

Are you currently working? Yes No If No, when was the last date that you worked?
| | | | | | |
Were you working at the time of the accident? Yes No

If Yes, what type of work were you doing?
Did you work at least 26 weeks of the previous 52 weeks preceding the accident or were you receiving Employment Insurance
during that time?
Yes No
Were you receiving Employment Insurance at the time of the accident? Yes No
Were you the primary caregiver for anyone you lived with at the time of the accident? (see Part 6 for definition) Yes No
Were you enrolled in an education program (elementary, secondary, post-secondary or continuing education) at the time of the
accident? Yes No

Part 2 Name of Insurance Company City or Town of Branch Office (if applicable)
Insurance
Company Name of Insurance Company Representative E-mail (optional)
Information
Telephone Fax
To be completed by - - - -
the applicant
Name of Policy Holder same as: Policy Holder Last Name Policy Holder First Name
Applicant OR
Part 3 Give a brief description of the accident and what happened to you. Please describe any injuries you sustained as a direct result
Accident of the accident.
Description
To be completed by
the applicant
 additional sheets attached
Part 4 I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional, social worker, or
rehabilitation expert properly identified by my insurer to conduct an examination, only such information relating to my health
Applicant
condition and treatment received as a result of the automobile accident and any pre-existing or subsequently occurring health
Signature conditions that may be barriers to my recovery as a result of the automobile accident, as is reasonably required for the purpose of
providing treatment and determining my eligibility for benefits. I authorize the health practitioner who completes this form to
contact my employer, if this is necessary, to confirm the essential tasks of my employment and the nature and extent of any
available work with modified hours or duties.
This authorization does not apply to a consultation between my health care provider and the insurer’s health professional
conducting an examination Separate express consent is required for this consultation. This consent should be in writing.
or representation to an insurer under a contract of insurance.

To the Health Practitioner:
Please complete the following information based on your most recent examination of the applicant named in Part 1 and return the form to the insurance
company listed in Part 2. Please print clearly.
Part 5 Provide a description (list most significant first) and associated ICD-10-CA code for any injuries and sequelae that are the direct
Injury and result of the automobile accident. (Refer to the User manual at www.hcaiinfo.ca for ICD-10-CA coding information.)
Sequelae
Information Description Code
This part and the

rest of this form
must be completed
by your Health
Practitioner
Part 6 Date symptoms first appeared: _ _ _ _ /_ _ / _ _ (YYYYMMDD)

Disability Date of most recent examination: _ _ _ _ /_ _ / _ _ (YYYYMMDD)
Date of first post-accident examination: _ _ _ _ /_ _ / _ _ (YYYYMMDD)
Tests and
Information Is the applicant substantially unable to perform the essential tasks of his/her employment at the time of the accident
To be completed
as a result of and within 104 weeks of the accident? Yes No N/A
by the health
practitioner Can the applicant return to work on modified hours and/or duties? Yes No N/A
If yes, please explain:
Does the applicant suffer a complete inability to carry on a normal life? (i.e., Has the applicant Yes No
sustained an impairment that continuously prevents the person from engaging in substantially
all of the activities in which the person ordinarily engaged before the accident?)
If yes, please explain:
As the Primary Caregiver, does the applicant suffer a substantial inability to engage in the Yes No
caregiving activities in which he/she engaged at the time of the accident? (Primary Caregiver
means that, at the time of the accident, the applicant was residing with a person in need of care
and the applicant was the primary caregiver for the person in need of care and did not receive
any remuneration for engaging in caregiver activities.)
Is the applicant, as a result of the accident, unable to continue in an elementary, secondary, Yes No
post-secondary or continuing education program that the applicant was enrolled in at the time of
the accident?
Does the applicant suffer a substantial inability to perform the housekeeping and home Yes No
maintenance services that he/she normally performed before the accident?

If you responded ‘Yes’ to any disability test above, what is the anticipated duration? 1-4 weeks
5-8 weeks
9-12 weeks
more than 12
weeks
If you responded Anticipated Duration ‘more than 12 weeks’ to any disability test above, please explain why the
task/activity limitations are likely to persist beyond 12 weeks.
Please explain:
Part 7 a) Have there been any examinations, investigations, or consultations not previously reported by you?
Further No Yes (please specify findings and results)
Investigations
or
Consultations
b) Are further examinations, investigations or consultations contemplated or required?
No Yes (please specify)
Part 8 a) Prior to the accident, did the applicant have any disease, condition or injury that affected his/her ability to
Prior and perform the activities listed in Part 6?
Concurrent No Unknown Yes (please explain)
Conditions
If yes, is the applicant currently receiving any disability benefits for the pre-existing disease, condition or injury?
No Unknown Yes (please explain)
If you treated the applicant for similar conditions prior to the accident, please describe (include date of onset,
any subsequent interventions, and status at the time of the accident).
b) Since the automobile accident, has the applicant developed any disease, condition or injury, not related to the
accident, that could affect his/her disability?

Part 9 a) Please list any medications (including dosage and frequency) that the applicant is currently taking for injuries related to the
Medications automobile accident.
Were these medications prescribed by you? No Yes
b) Please list any medications (including dosage and frequency) that the applicant is currently taking as a result of prior or
concurrent conditions identified in Part 8.
Were these medications prescribed by you? No Yes
Part 10 Name of Health Practitioner College Registration Number

Health Facility Name (if applicable) AISI Facility Number (if applicable) You are a:
Practitioner Chiropractor
Signature Dentist
Address Nurse Practitioner
Occupational Therapist
City Province Postal Code Optometrist
Physician
Physiotherapist
Telephone Number Extension Fax Number Psychologist
- - - - Speech-Language
Email Address Pathologist
or representation to an insurer under a contract of insurance. Regulated sectors may be subject to an examination or inquiry
about matters in connection with a licence and or unfair or deceptive act or practice. Non-compliance with applicable regulations
may result in enforcement actions ranging from an administrative monetary penalty to prosecution under the Provincial Offences
Act.
Name of Health Practitioner (please print) Signature of Health Practitioner Date (YYYYMMDD)
Note: The fee for completing this certificate is not a health care benefit of the Ontario Ministry of Health and Long-Term Care. This fee should be billed
to the insurer directly.

Permission to Disclose
Health Information (OCF-5)
Use this form for accidents that occur on or after January 1, 1994.
Collection, use and disclosure of this information is subject to all applicable
privacy legislation.

Date of Accident:
(YYYYMMDD)
2023-11-06
Last Name First Name and Initial Date of year month day
Part 1 Accident
Applicant Address
Information
Birth year month day Home Telephone Work Telephone Extension

Date
Name of Insurance Company

Part 2
Insurance Name of Insurance Company Representative
Company
Information
Address City
Province Postal Code Telephone Number FAX Number
Name of Health Professional Health Profession

Part 3
Treating Address
Health
Professional City Province Postal Code
Telephone Number FAX Number
I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional,
Part 4 social worker, or vocational rehabilitation expert properly appointed by my insurer to conduct an examination,
Signature only such information relating to my health condition and treatment received as a result of the automobile
accident and any pre-existing or subsequently occurring health conditions that may be a barrier to my recovery
as a result of the automobile accident, as is reasonably required for the purpose of providing treatment and
determining my eligibility for benefits. This authorization is valid until my claim for Statutory Accident Benefits
has been concluded or until I withdraw this consent. (Please note withdrawal of this consent may impact your
benefit entitlement).
This authorization does not apply to a consultation between my health care provider and the insurer’s health
professional conducting an examination. Separate express consent is required for this consultation. This
consent should be in writing.
Effective (2010-09-01) OCF–5

FSCO (1225E) Page 1 of 1
Expenses Claim Form
(OCF-6)
Use this form for accidents that occur on or after January 1, 1994
Date of Accident:
(YYYYMMDD)
2023-11-06
Only use this form to claim expenses not submitted on your behalf by your health care provider.
You can apply for reasonable and necessary expenses incurred as a result of the accident and not covered under another plan. Such
expenses may include the costs of medical and rehabilitation treatment, lost educational expenses, caregivers, attendant care and
housekeeping services, transportation expenses, expenses of visitors, and the cost to repair or replace lost or damaged clothing,
dentures, glasses, prostheses, hearing aids, etc. Please attach all bills and receipts.
Part 1 Last Name First Name and Initial Gender

Information
Address
Birth date (yyyy/mm/dd) Home Telephone Work Telephone Ext
Part 2 Attach all bills and receipts. If a bill or receipt is not available, please explain. If you need more space, please attach additional sheets.
Expenses Item Date Description of Goods and Services and Name of Service Provider Amount
additional sheets
attached
Total Amount
Part 3 I certify that the information provided is true and correct. I understand that it is an offence under the Insurance Act to
Signature knowingly make a false or misleading statement or representation to my insurer under a contract of insurance. I
further understand that it is an offence under the federal Criminal Code for anyone, by deceit, falsehood, or other
dishonest act, to defraud or attempt to defraud an insurance company. I further understand that the use and
disclosure of information contained on this form is subject to the terms described on my Application for Accident
Benefits.
Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (yyyy/mm/dd)
Effective (2010-09-01) OCF-6

FSCO (1227E) Page 1 of 1
Treatment
Confirmation Form
(OCF-23)
Use this form for accidents that occur on or after September 1, 2010.
**Claim Number: 002373921
**Policy Number: 4000729543
Date of Accident:
(YYYYMMDD) 2023-11-06
To the Applicant: To the Initiating Health Practitioner:
Please provide information for the completion of Parts 1, 2 and 3. After your
health practitioner has reviewed your Treatment Confirmation Form with you, For accidents that occur on or after September 1, 2010, this form is to be used for goods and
sign Part 9. services provided in accordance with the Minor Injury Guideline.
Your health practitioner will complete all other parts of the form. A Health Practitioner who is authorized by law to treat the impairment, who is authorized
under the applicable Guideline to complete this form, and who will be the Health Practitioner
Collection, use and disclosure of this information are subject to all applicable responsible for providing the goods and services described in this form must sign Part 4.
privacy legislation. Additional disclosure and consent may be required
depending on the manner in which the information is used and disclosed. Consent: It is the responsibility of Health Practitioners to ensure that their collection, use
As indicated on the form, all attachments are sent directly to the insurer. and disclosure of information submitted are authorized by a consent form. The Ontario
Claims Form 5 (OCF-5) Permission to Disclose Health Information may be used as a
All fields must be completed subject to the following exceptions: consent form.
*required if known
**at least one field in this section
***optional
Part 1 Date Of Birth (YYYYMMDD) Gender *Telephone Number Extension

Last Name
Information
First Name ***Middle Name
To be provided by
the applicant
Address
Part 2 Company Name City or Town of Branch Office (if applicable)
Insurance
*Adjuster Last Name *Adjuster First Name
Company
Information
*Adjuster Telephone Extension *Adjuster Fax
To be provided by
the applicant **Name of Policy Holder: **Policy Holder Last Name *Policy Holder First Name
Same as Applicant , OR:
Part 3 OTHER INSURANCE: Is there other insurance coverage for any goods and services listed in this Treatment Confirmation Form?
Other I have made reasonable enquiries of the applicant and have determined that:
Insurance
Information NO There is no other insurance coverage identified YES There is other insurance coverage that is potentially
for these goods and services available to cover/partially cover these goods and services.
To be completed MOH Is there Ministry of Health and Long-Term Care (MOH) coverage for any goods and services included in this plan?
by the Initiating
Yes No Not applicable
Health Practitioner
with Information *Other Insurer Name *Other Insurance Plan Or Policy Number
from the Applicant Other
Insurer
*Name of Plan Member *Other Insurer’s Identifier
1
*Other Insurer Name *Other Insurance Plan Or Policy Number

Other
Insurer
*Name of Plan Member *Other Insurer’s Identifier
2
Effective Date (2016-10-01) © Queen's Printer for Ontario, 2016 OCF-23

Part 4 Name of Initiating Health Practitioner (please print) College Registration Number
Signature of
Facility Name (if applicable)
Initiating You are a:
Health HCAI Facility Registry Number FSCO Licence Number (if applicable) Chiropractor
Practitioner Dentist
Service Address Nurse Practitioner
I am not the Occupational
first Initiating City Province Postal Code Therapist
Health Practitioner Physician
Telephone Number Extension *Fax Number Physiotherapist
*Email Address
TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED:
I UNDERSTAND that you, and persons acting for you, will collect business, personal and personal health information that is related to the applicant’s
claim for accident benefits arising out of the accident referenced in this Treatment Confirmation Form and that all such information will be collected
directly from me or from any other person with my consent.
I ALSO UNDERSTAND that you and persons acting for you will collect information about this Treatment Confirmation Form prepared by me.
I ALSO UNDERSTAND that as the initiating health practitioner for the applicant that you, and persons acting for you, will collect information related to
this claim that is provided by me on this or any other auto insurance claim form.
I ALSO UNDERSTAND that the information within this form will be collected and used only as reasonably necessary, with the applicant’s consent,
for the purposes of:
• Investigating the claims of the applicant and processing the claims of the applicant as required by law, including the Ontario Automobile
Policy;
• Obtaining or verifying information relating to the applicant’s claims in order to determine entitlement and the proper amount of payment;
• Recovering payment from insurers and others liable in law for amounts that you pay in connection with the applicant’s claims;
• Identifying and analysing the nature and costs of goods and services that are provided to automobile insurance claimants by health care
providers;
• Preventing, detecting and suppressing fraud;
• Compiling anonymized statistics for government agencies; and
• Assessing underwriting risks and claims experience.
I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons or organizations, who may collect
and use this information only as reasonably necessary to enable you or them to carry out the purposes described above:
Insurers; insurance adjusters, agents and brokers; employers; health care providers; hospitals; accountants; financial advisors; solicitors;
organizations that consolidate claims and underwriting information for the insurance industry; fraud prevention organizations; other insurance
companies; the police; databases or registers used by the insurance industry to analyze and check information provided against existing information;
and my agents or representatives as designated by me from time to time.
I ALSO UNDERSTAND that you, and persons acting for you, may pool this information with information from other sources and may analyse this
information for the limited purpose of preventing, detecting or suppressing fraud.
I CONSENT to you collecting, using and disclosing information relating to this Treatment Confirmation Form in the manner described above, which
will be limited to information that is reasonably necessary to meet the legitimate purpose of such collection, use or disclosure.
I UNDERSTAND that if I have any questions about this consent I am free to consult with the insurance company representative or a legal advisor
before signing this document.
I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose this information to others without my
knowledge or consent.
I certify that the goods and services contemplated are reasonable and necessary for the treatment and rehabilitation of the applicant for the injuries
identified in Part 5 and the treatment proposed is in accordance with the Minor Injury Guideline (if the accident occurred on or after September 1,
2010). I have reviewed the proposed treatment with the applicant.
I certify that the information provided is true and correct. I understand that it is an offence under the Insurance Act to knowingly make a false or
misleading statement or representation to an insurer under a contract of insurance. Regulated sectors may be subject to an examination or inquiry
about matters in connection with a licence and or unfair or deceptive acts or practices. Non-compliance with applicable regulations may result in
enforcement actions ranging from an administrative monetary penalty to prosecution under the Provincial Offences Act.
I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone, by deceit, falsehood, or other
dishonest act, to defraud or attempt to defraud an insurance company. This information will be used for processing payments of claims; identifying
and analysing the nature, effects and costs of goods and services that are provided to automobile accident victims, by health care providers; and
PREVENTING, DETECTING AND SUPPRESSING FRAUD.
To obtain further information about privacy related issues please contact the Privacy Officer for the insurance company listed in Part 2.
To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit
http://www.ibc.ca/en/privacy-terminology.asp
Name of Initiating Health Practitioner (please print) Signature of Initiating Health Practitioner Date (YYYYMMDD)

To the Health Practitioner:
Please complete the following information based on your most recent examination of the applicant named above and return the form to the insurance
company listed in Part 2. Please print clearly.
Part 5 Provide a description (list most significant first) and associated ICD-10-CA code for injuries and sequelae that are the direct result
Injury and of the automobile accident (refer to the User manual at www.hcaiinfo.ca for ICD-10-CA coding information).
Sequelae Injury Description Injury Code
Information
Part 6 a) Was the applicant employed at the time of the accident?

Prior and Yes No
Concurrent
b) Prior to the accident, did the applicant have any disease, condition or injury that could affect his/her response to treatment for
Conditions the injuries identified in Part 5?
c) If Yes to “b” above, did the applicant undergo investigation or receive treatment for this disease, condition or injury in the past
year?
No Unknown Yes (please explain and identify provider, if known)
Part 7 a) Have you identified any barriers to recovery that may affect the success of this treatment for this particular applicant? (For
assistance in identifying barriers to recovery, please refer to the user manual at www.hcaiinfo.ca.)
Barriers to
No Yes (please explain)
Recovery
Part 8 I direct the insurer, including the Motor Vehicle Accident Claims Fund, to pay the licensed service provider directly for that
Direct portion of the approved goods and services specified on this Treatment Confirmation Form (OCF-23) that are not covered by
extended/supplementary health insurance.
Payment
Assignment Applicants that have extended/supplementary health insurance responding to a claim may need to provide payment out of
by Applicant pocket before the extended/supplementary health insurer reimburses the claimant.
(only applicable to
applicants Applicant Initials
obtaining
treatment/service
from a licensed
service provider)

Part 9 I have reviewed this form. I have been informed about and agree with the proposed treatment. I certify that, to the best of my
Signature of knowledge, the information I have provided is accurate. Payment for this treatment is pre-approved, and/or subject to the approval
of the insurer. For services requiring insurer approval, I understand that, if I undertake those services prior to approval by the
Applicant insurer, I may be responsible to my provider for any goods or services provided. All services are subject to coverage issues or
exclusions.
I consent to sharing of personal information between my Initiating Health Practitioner and my insurer. If this OCF-23 is not being
completed by the first Initiating Health Practitioner, I consent to the insurer contacting the first Initiating Health Practitioner to
determine the amount of the Guideline goods and services that have been consumed.
TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED:
I UNDERSTAND that you, and persons acting for you, will collect personal information and personal health information about me
that is related to my claims for accident benefits arising out of the accident described in this application, and that all such information
will be collected directly from me or from any other person with my consent.
I ALSO UNDERSTAND that you and persons acting for you will collect information about my driving record, automobile insurance
policy history and automobile insurance claims history if they exist.
I ALSO UNDERSTAND that if I am the holder of an automobile insurance policy, you, and persons acting for you, will collect the
driving record, automobile insurance policy history and automobile insurance claims history of any listed drivers on my automobile
insurance policy or other drivers whom I have permitted to drive my automobile.
I ALSO UNDERSTAND that the information described above will be collected and used only as reasonably necessary for the
purposes of:
 Investigating my claims and processing my claims as required by law, including the Ontario Automobile Policy;
 Obtaining or verifying information relating to my claims in order to determine entitlement and the proper amount of payment;
 Recovering payment from insurers and others liable in law for amounts that you pay in connection with my claims;
 Identifying and analyzing the nature and costs of goods and services that are provided to automobile accident victims by
health care providers;
 Preventing, detecting and suppressing fraud;
 Compiling anonymized statistics for government agencies; and
 Assessing underwriting risks and claims experience.
I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons or organizations,
who may collect and use this information only as reasonably necessary to enable you or them to carry out the purposes described
above:
Insurers; insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants; financial advisors;
solicitors; organizations that consolidate claims and underwriting information for the insurance industry; fraud prevention
organizations; other insurance companies; the police; databases or registers used by the insurance industry to analyze and check
information provided against existing information; and my agents or representatives as designated by me from time to time.
I ALSO UNDERSTAND that you, and persons acting for you, may pool this information with information from other sources and may
analyze this information for the limited purpose of preventing, detecting or suppressing fraud.
I CONSENT and, if I am the holder of an automobile insurance policy, declare that I have obtained consent from the listed drivers
on my policy and any other drivers whom I have permitted to drive my automobile, to you collecting, using and disclosing this
information in the manner described above, but no more of such information than is reasonably necessary to meet the legitimate
purpose of such collection, use or disclosure.
I UNDERSTAND that if I have any questions about this consent I am free to consult with my insurance company representative or
legal advisor before signing this document.
I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose this information to others
without my knowledge or consent.
I CERTIFY that the information provided is true and correct.
falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company.
To obtain further information about privacy related issues please contact the Privacy Officer for the insurance company listed in
Part 2.
To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit
http://www.ibc.ca/en/privacy-terminology.asp.

Applicant Name: Policy Number:
Provider Name: OCF-23 Claim Number:
Provider Fax: Date of Accident:
Part 10 Category Description Maximum Fee Estimated Fee

Guideline
Minor Injury Guideline
Services
**Supplementary
Goods & Services
**Other Pre-approved
Services (including radiology)
Total
Are there any attachments? Yes No If yes, how many? _______
Send any attachments directly to the insurer
Part 11 ***I waive the requirement of the Applicant’s signature.

Signature of I have reviewed this Treatment Confirmation Form, and based upon the information provided,
Insurer I confirm that the policy referred to in Part 2 was in force at the time of the accident.
Approve Do not approve
(explanation to follow or attached)
Name of Adjuster (please print) Signature of Adjuster Date (YYYYMMDD)
To the insurer: Please provide a copy of this page to the Applicant and the Initiating Health Practitioner indicated in Part 4.

Policy No.:4000729543
Claim No.:002373921
Date of Loss:November 6, 2023
The Co-operators Group and Your Privacy
In the course of handling claims, we will collect and use information from you and others for the following
purposes:
●
To investigate and verify claims.
●
To assess the damage or injury and determine eligibility for benefits.
●
To manage claims as required (e.g. property repairs, rehabilitation).
●
To settle any disputes.
●
To obtain compensation or contribution from third parties.
●
To prevent fraud.To analyze risk and business needs.
●
As required by law or to meet regulatory requirements.
●
For these and other purposes.
We will, where necessary or appropriate, collect information from or disclose information to third parties
such as police, witnesses, property valuators, health professionals, your employer, industry databases
and credit reporting agencies. As required, we will exchange information with other insurers, industry
organizations, government agencies and your benefits providers.
We will obtain your express consent for any sensitive personal information, such as health or financial
records, except where authorized by law. We are committed to safeguarding the personal information you
provide to us, and will only retain the information for as long as required.
For more information on our Privacy Policy, contact the claims representative, visit our website at
www.cooperators.ca, or contact:
Co-operators Privacy Officer

Priory Square,
Guelph, ON, N1H 6P8
Phone: 1-888-887-7773
E-mail: privacy@cooperators.ca
Travel Expense Form - Ontario
Mileage expenses are paid at a rate of 40 cents per km. For each round trip a 50 km deductible is applied.
To medical Distance Health Professional’s
Date of Visit From Round Trip Health Professional
facility (km) Signature
Client: Policy No.:
Date: Signature of Client:
CLG745
EMPLOYEE BENEFITS INFORMATION
For Calculation of Income Replacement Benefit
PLEASE HAVE THIS FORM COMPLETED IF BOTH OF THE FOLLOWING APPLY:
1. Before the accident, your Employer paid premiums for your benefits or contributed to a pension plan on your behalf AND,
2. After the accident, your Employer stops making these payments or contributions.
Employee Name: ________________________________________
EMPLOYEE BENEFIT TYPE Amount paid by Employer PRIOR to Taxable Non- Payments continued Post
(Please Specify) accident. (e.g. $/month, $/week, $/year) Taxable accident?
Yes; Amount Paid No
Extended Health: Medication, Drug,
Vision, etc.
Dental
Income Continuation: STD, Sick
days, Sick Leave etc.
Income Continuation: LTD
Life Insurance
Pension Plan, Retirement Plan, etc.
Other
Note: This information is required in addition to the Employers Confirmation of Income (OCF-2/59)
COMPLETED BY:
Employer:_________________________________ Date: ___________________________
Name: _________________________________ Signature: ______________________________________
If you have any questions please contact your Co-operators Claims Representative.
Please return to Co-operators.
CLG645(09/05)

Accident Claim#002373921 Stephen Forde OCB1 Form

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5600 CANCROSS COURT

MISSISSAUGA ON L5R 3E9

Auto Policy No.: 4000729543

How to Apply for Accident Benefits

Understanding the Claims Process

If you have any questions, contact me at kaitlin_mitchell@cooperators.ca or 1-905-434-4042.

What are Accident Benefits?

Accident Benefits Application Package

Where do I send the Completed Forms?

What is the Minor Injury Guideline?

How do I Claim a Weekly Benefit?

What Other Benefits are Available?

What if I have Questions?

Co-operators and Your Privacy

About this Application for Accident Benefits

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

2. If You are a Listed Driver

The following categories only apply if:

3. Occupant of Somebody Else’s Automobile

6. None of the Above Apply

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Claim Number: 002373921

Applicant Stephen Forde Male Female

City Province Postal Code

Work Telephone Fax Number E-mail:

Part 3 Date of Year Month Day Time of a.m. Driver Pedestrian

Officer Name Badge No. Date accident Year Month Day

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Additional sheets attached

Insurance Company Policy Number

Automobile – Make, Model, Year Licence Plate Number

Insurance Company Policy Number

Automobile – Make, Model, Year Licence Plate Number

Owner of the Vehicle Home Telephone

Address Work Telephone

City Province Postal Code

Automobile – Make, Model, Year Licence Plate Number

Insurance Company Policy Number

Name of Policyholder Driver’s Licence Number

Insurance Company Type of Insurance

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Address Program and Level

Year Month Day

Additional sheets attached

Yes (Explain below) From what date? Year Month Day

Additional sheets attached

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Additional sheets attached

Last fiscal year (self-employed only)

Year Month Day Year Month Day

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Stephen Forde 2023/12/17

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-1

Part 1 Last Name First Name and Initial Gender

City Province Postal Code

Birth Date (YYYYMMDD) Home Telephone Work Telephone

Name of Insurance Company

City Province Postal Code

Other Insurer Name Other Insurance Plan Or Policy Number