Accident Benefits Claim Referral Form

All information submitted through our online forms are encrypted using SSL technology. You will receive an email copy of your submission. We will contact you to confirm receipt of the assignment and to obtain any further details.

ADJUSTER
Company Name*
Adjuster's Name*
FirstLast
Address*
Street AddressAddress Line 2CityProvincePostal Code
Email*
Phone*
Fax
CLAIMANT
Claimant's Name*
FirstLast
Address
Street AddressAddress Line 2CityProvincePostal Code
Date of Birth
Occupation
Employment Status
- Employed
- Self-employed
- Unemployed
LEGAL REPRESENTATIVE (if applicable)
Firm Name
Legal Representative's Name
FirstLast
Address
Street AddressAddress Line 2CityProvincePostal Code
Phone
Fax
CLAIM / POLICY INFORMATION
Claim Number*
Policy Number*
Date of Loss*
Optional Benefits*
- None
- $600
- $800
- $1000
DOCUMENTATION RECEIVED (Please forward to us)
Please forward to us by fax, mail or send securely by using the "Secure Deposit Box" button below which will open a new browser tab to the right of this form page. Complete your document(s) upload there and then return to this tab to continue and complete this form submission.
Secure Deposit Box
Please select all documents that will be forwarded to us
- Application (OCF-1)
- Employer’s Confirmation (OCF-2)
- Claimant's Statement
- Statutory Declaration
- SABS Initial Contact Form
- Income Tax Returns
- Financial Statements
Other Information
Extent of Injuries
Expected duration of claim
Any collateral benefits?
- Yes
- No
Any IRBs Paid?
- Yes
- No
Has the claimant returned to work?
- Yes
- No
COMMENTS
Please add any details or comments in the field below:

Back to top

Insignia Forensic Group

Accident Benefits Claim Referral Form

ADJUSTER

CLAIMANT

LEGAL REPRESENTATIVE (if applicable)

CLAIM / POLICY INFORMATION

DOCUMENTATION RECEIVED (Please forward to us)

Other Information

COMMENTS