Consultation Request - Accident Law Group

Accident Lawyer free Consultation

Accident Law Group provides a free consultation session with an accident lawyer to discuss your case. We educate our clients about accident benefit settlements and accident benefits claim in Ontario. To book for an accident lawyer free consultation session, fill out the Accident Benefits Application Package form below.

Accident Benefits Application Package

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.
Please complete the following form (OCF-1)

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 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).
- No - If none apply, continue to 2
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 issued the policy you are listed on.
- No - If no, continue to 3.
- 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 insures this automobile.
- No - If no, continue to 4.
4. Pedestrian or Bicyclist
Were you a pedestrian or a bicyclist struck by an automobile that was insured at the time of the accident?*
- Yes - If yes, send your forms to the insurance company of the automobile that struck you.
- No - If no, continue to 5.
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 other automobile that was involved in the accident.
- No - If no, continue to 6.
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.
Application for Accident Benefits (OCF-1)
Return this form to:*
Use this form for accidents that occur on or after November 1, 1996.
Claim Number:*
Policy Number:*
Date*
YYYY dash MM dash DD
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 Applicant Information
First Name and Initial*
Last Name*
Marital Status
- Single
- Married
- Common-law
- Separated
- Divorced
- Widow(er)
Gender*
- Male
- Female
Address*
City*
State / Province*
ZIP/ Postal Code*
Is anyone dependent on you for financial support or care?*
- Yes, how many persons?
- No
Home Telephone*
Work Telephone*
Fax Number*
What is the best time to reach you:*
MM slash DD slash YYYY
You can be reached
- by telephone
- by personal visit
- Third Choice
- at home
- at work
- other
Time*

: HH

MM

AM/PM
UntitledLanguage Spoken:*
Email*
Part 2 Applicant’s Representative (if applicable)
Last Name*
First Name and Initial*
Relationship with applicant*
- Parent
- Lawyer
- Other Paid Representative
- Guardian
- Other
Address*
City*
Province*
Postal Code*
Work Telephone*
Fax Number*
E-mai*
Part 3 Details and Health Information
Date of Acciden*
MM slash DD slash YYYY
Time of Accident*

: HH

MM

AM/PM
You were a:*
- Driver
- Passenger
- Pedestrian
- Other
Accident Location: Hwy. No./Street Name*
City*
Province*
Did the accident occur while you were at work?*
- Yes
- No
Was the accident reported to the police?
- Yes
- No
Did you file a claim with the Workplace Safety and Insurance Board?*
- Yes
- No
Officer Name*
Badge No*
Police Department/Collision Reporting Centre*
Date accident reported to the police*
MM slash DD slash YYYY
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.*
Were you charged?*
- Yes
- No
Were you able to return to your normal activities following the accident?*
- Yes
- No
Did you go to see a health professional? (for example: physician, chiropractor, physiotherapist?)*
- Yes
- No
Did you go to the hospital?*
- Yes
- No
Name of Health Professional*
Name of Facility*
Address*
City*
Province*
UntitledPostal Code*
Has this Health Professional begun any treatment?*
- Yes
- No
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, Details of complete the following:
Part 4 Details of Automobile Insurance
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*
License 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*
Insurance Company*
Policy Number*
Automobile – Make, Model, Year*
License Plate Number*
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.
Vehicle type covered by this policy:
- Passenger
- Motorcycle
- Taxi/Limousine
- Truck
- Bus
- Snowmobile
- Other
The policy you are claiming under insures:
- The vehicle I was riding in at the time of the accident
- The vehicle that struck me as a pedestrian/bicyclist
- Another vehicle that was involved in the accident
Owner of the Vehicle*
Home Telephone*
Home Telephone*
Work Telephone*
City*
Postal Code*
Province*
Automobile – Make, Model, Year*
Insurance Company*
Policy Number*
Name of Policyholder*
License Plate Number*
Did you report the accident to any other insurance company?*
- Yes (provide details)
- No
Insurance Company*
Type of Insurance*
Part 5 Applicant Status
Which of the following describes your status at the time of the accident?
Not Employed
- Unemployed
- Unemployed and,
- have worked 26 weeks in the past 52 weeks
- receiving Employment Insurance Benefits
- Retired
- Student or recent graduate
- Caregiver
Employed
- Employed and working
- Self-Employed
Part 6 Student Attending School
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?
Yes (Give details below)*
- Yes (Give details below)
- No (Continue to Part 7)
Name of School*
Program and Level*
Date Last Attended*
MM slash DD slash YYYY
Projected Date for Completion of Studies*
MM slash DD slash YYYY
Address*
City*
Province*
Postal Code*
Are you now attending school?
- Yes (Enter date)
- No
Were you able to return to school after the accident?(
- Yes (Enter date)
- No
Are you now attending school?*
MM slash DD slash YYYY
Were you able to return to school after the accident?*
MM slash DD slash YYYY
Part 7 Caregiver
Were you the main caregiver to people living with you, at the time of the accident?
- 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
Name Date of Birth Disabled
Did your injuries prevent you from performing the caregiving activities you did prior to the accident?
- Yes (Explain below)
- No
At any period since the accident, were you able to return to caregiving?
- Yes
- No
From what date?
MM slash DD slash YYYY
From what date?
MM slash DD slash YYYY
Explanation
Part 8 Income Replacement Determination
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 deductions.
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.
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.
From Year/Month/Day To Year/Month/Day Name and Address of Most Recent Employer Position/Essential Tasks No. of Hours Per week Gross Income for the period
Did your injuries prevent you from working?
- 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 (From what date?)
- No
Did your injuries prevent you from working?
YYYY slash MM slash DD
At any period since the accident, were you able to return to work since the accident?
YYYY slash MM slash DD
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 Other Insurance or Collateral Payments
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.)?
- Yes (Give details below)
- No
During the past 52 weeks, did you receive any income from a disability plan?
- Yes (Enter dates)
- No
Yes (Give details below)
Name of Benefit Payor Type of Coverage Policy or Certificate Number
From:
YYYY slash MM slash DD
To:
YYYY slash MM slash DD
Total Amount Received
Are you receiving Employment Insurance Benefits?
- Yes (Enter dates)
- No
From:
YYYY slash MM slash DD
To:
YYYY slash MM slash DD
Total Amount Received
Are you receiving Social Assistance Benefits (welfare)?
- Yes
- No
Part 10 Motor Vehicle Accident Claims Fund
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
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)
Date
MM slash DD slash YYYY
Signature*
Motor Vehicle Accident Claims Fund
P.O. Box 85
5160 Yonge Street
Toronto, ON M2N 6L9
Toronto calling area: (416) 250-1422
Toll Free: 1-(800) 268-7188
Part 11 Signature
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;
- ecovering 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 carr 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.

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 Make
Date*
YYYY slash MM slash DD
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

get ACCIDENT BENEFITS ONTARIO

Get a car accident lawyer free consultation session and know accident benefits in Ontario for automobile accidents, accident benefits settlement Ontario and an estimate of car accident lawyer fees by filling out the form above. Submit the form and Accident Law Group will get back to you.

Accident Law Group

We Fight Your Accident Cases

Accident Lawyer free Consultation

Accident Benefits Application Package

About this Application for Accident Benefits

■ Application for Accident Benefits (OCF-1)

Please complete the following form (OCF-1)

1. If You Own, Lease, or Have Regular Use of a Company Automobile

2. If You are a Listed Driver

3. Occupant of Somebody Else’s Automobile

4. Pedestrian or Bicyclist

5. Uninsured Automobile

6. None of the Above Apply

Application for Accident Benefits (OCF-1)

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 Applicant Information

Part 2 Applicant’s Representative (if applicable)

Part 3 Details and Health Information

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, Details of complete the following:

Part 4 Details of Automobile Insurance

Part 5 Applicant Status

Part 6 Student Attending School

Part 7 Caregiver

Part 8 Income Replacement Determination

Part 9 Other Insurance or Collateral Payments

Part 10 Motor Vehicle Accident Claims Fund

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

Part 11 Signature

TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED:

get ACCIDENT BENEFITS ONTARIO

FREE CONSULTATION

OUR OFFICE LOCATION

CONTACT ACCIDENT LAW GROUP

Name	Date of Birth	Disabled

From Year/Month/Day	To Year/Month/Day	Name and Address of Most Recent Employer	Position/Essential Tasks	No. of Hours Per week	Gross Income for the period

Name of Benefit Payor	Type of Coverage	Policy or Certificate Number