accident benefit forms

To receive accident benefits from your auto insurer after an accident, you will need to use the following forms.  The forms are available in Adobe Reader (PDF) format at the Financial Services Commission of Ontario website, and can be downloaded and printed.

There are five forms in this package (which are also available separately):

Application for Accident Benefits (OCF-1)

(PDF Fillable Form)

The 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)

(PDF)

This form is to be completed only if you are claiming Income Replacement Benefits – if you were employed for at least 26 weeks in the year prior to the accident and are unable to return to work for more than a week after the accident.

Disability Certificate (OCF-3)

(PDF Fillable Form)

This form must be filled out by you and your treating doctor or other health practitioner (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician, physiotherapist, occupational therapist, speech language pathologist or psychologist).

Permission to Disclose Health Information (OCF-5)

(PDF Fillable Form)

This form allows the insurance company access to your personal medical records.  Do not fill out this form unless the adjuster handling your claim specifically requests it. Ask the adjuster which records are required and why, and be sure to write on the form the specific dates to which you are permitting the insurance company to access.

Pre-approved Framework Treatment Confirmation Form (OCF-23)

(PDF Fillable Form)

This form only needs to be filled out if your injuries fall into certain categories and you insurance company requests it.

Election of Income Replacement, Non-Earner, or Caregiver Benefit (OCF-10)

(PDF Fillable Form)

Although you may be eligible for the Income Replacement Benefit, Non-Earner Benefit and/or the Caregiver Benefit listed in Explanation of Benefits Payable by Insurance Company (OCF-9), you can only receive one of these benefits. You must choose which benefit you wish to receive. If you need help in choosing the benefit, please contact a lawyer or your insurance company representative immediately. Return this form no later than 30 days from the day you received it. Make a copy for your own records.

Application for Expenses (OCF-6)

(PDF Fillable Form)

Use this form to submit expenses such as medication; physiotherapy, massage or other treatment approved by the insurer; babysitting; attendant care; housekeeping or home maintenance; transportation; destroyed clothing or glasses, etc.  Original receipts for the expenses you claim must be submitted with this form.  Here are sample receipts for housekeepers, babysitters or attendant caregivers who may be friends or family rather than professionals. 

Activities of Normal Life (OCF-12)

(PDF) (Fillable MS-Word)

Your insurance company may ask you to fill out this form if you claim or they think you may be eligible for housekeeping, attendant care or non-earner benefits.

Declaration of Post-Accident Income and Benefits (OCF-13)

(PDF)

If you are unable to work at your normal job or regular hours, but are able to work to some extent or get disability benefits from your work, use this form so that your insurer can properly calculate the amount of your Income Replacement Benefit.

Application for Mediation (Form A)

(PDF Fillable Form)

Your insurer may refuse to pay a benefit for which you apply and to which you believe you are entitled.  If this happens, you must attempt to resolve the dispute through mediation before taking any other legal steps.  Use this form to have a mediator appointed by the Financial Services Commission of Ontario (FSCO).  FSCO mediation services are free for you.

If mediation does not resolve the dispute, and you still believe you are entitled to the benefit, you should contact a lawyer concerning your options.  If you continue to challenge your insurance company, they will hire a lawyer at this point to advise and represent them.  You have a choice of suing your insurer for breach of the insurance contract, or requesting a hearing before a FSCO arbitrator to resolve the issue.  FSCO arbitration is generally less expensive and quicker, but there are times when it is in your interests to sue them instead.  A lawyer can explain the benefits and problems with each option and recommend what might be best for you in your circumstances.