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
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
Optional Benefits*
- None
- $600
- $800
- $1000
DOCUMENTATION RECEIVED (Please forward to us)
Please forward to us by fax, mail or attach by using "Upload Documents" button below. You can upload a single ZIP file or upload individual files for each type of document received
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 documention received but not listed above?
Please provide a list of the documents received in the field below:
Upload Files
Drop files here or
Accepted file types: jpg, jpeg, png, pdf, doc, docx, gif, xls, xlsx, csv, txt, rtf, Max. file size: 64 MB.
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:

Insignia Forensic Group

168 Queen Street S, Suite 218, Mississauga, ON L5M 1K8

Accident Benefits Claim Referral Form

ADJUSTER

CLAIMANT

LEGAL REPRESENTATIVE (if applicable)

CLAIM / POLICY INFORMATION

DOCUMENTATION RECEIVED (Please forward to us)

Other Information

COMMENTS