Claim Referral Form
Date: 8/20/2008
STEP 1 of 2.
Complete and Submit Claim
STEP 2.
To submit your claim online, please be sure to
complete ALL required fields
within the sections marked (
) and
'click' the 'submit claim' button
at the bottom of the form.
Company Name
Name of Adjuster
Telephone
Fax
Email
Policy/Claim Number
Date of loss
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Claimant's Name
Telephone
Address
City
Province
Postal Code
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Date of birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
What kind of representation do you have?
Legal representation
Non-legal representation
--> Relationship
No representation
Contact Name
Firm Name
Address
City
Province
Postal Code
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Telephone
Fax
Email (optional)
Claim Type
Bill 59:
AB
Tort
Bill 164:
AB
Tort
Other:
Policy Details
Optional benefits purchased:
None
600
800
1000
Collateral benefits available?
Yes
No
Benefits paid to date?
Yes
No
Documentation Received
Application for Accident Benefits (OCF-1/59)
Employer's Confirmation of Income (OCF-2/59)
Claimant's Signed Statement
Financial documentation (please list):
Other documentation (please list):
Comments
