Form Ab-1a - Claim For Disability Benefits
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Claim for Disability Benefits
Form AB-1A
Print
For accidents that occur on or after October 1, 2004
Send this form to the
To be completed by Claimant / Representative
appropriate insurer:
or a Medical Doctor
Insurance Company
Policy Number
Fax #
Date of Accident:
(____)______-_________
(DD-MM-YYYY)
Part 1 – Claimant Information
Last Name
First Name
Middle Name(s)
Address
City, Town or County
Province
Postal Code
Telephone Number (Home)
Telephone Number (Work)
Fax Number
(Include area code)
(Include area code)
(Include area code)
Date Of Birth
Gender
(DD/MM/YYYY)
Male
Female
Part 2 – Claim for Disability Benefits
(To be completed by Claimant or Agent)
Are you claiming disability income benefits under the Automobile Accident Insurance Benefits Regulation?
Yes
No
If Yes, please complete the remainder of this part of the form. Your insurance claims adjuster may request additional information from you or
your medical practitioner at a later date to assist with the claims process. If No, then please do not complete or submit this form at this time.
Were you employed on the date of the accident?
Date first unable to work
(DD/MM/YYYY)
Yes
No
Between what dates are you claiming a Loss of Income?
To
History of Employment during the 12 months preceding the accident
Name of employer:
Name of employer:
Address:
Address:
From:
To:
From:
To:
Occupation:
Occupation:
If you were unemployed at the date of the accident, for how much of the 12 months preceding the accident were you employed and working?
Average gross weekly income
$
Are you entitled to disability or other income benefits from your employer or any other source as a result of this accident?
Yes
No
If yes, from whom?
Name
Amount
Per Wk/Month
1.
2.
3.
AB-1A (2006/01)
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