Fillable Automobile Accident Benefits Proof Of Claim Form printable pdf download

Automobile Accident Benefits Proof Of Claim Form

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CLAIM #: ___________________

AUTOMOBILE ACCIDENT BENEFITS PROOF OF CLAIM FORM

PERSONAL INFORMATION:

Last Name: ________________________ First Name: __________________________ Middle: ________

Address: _______________________________________________________Postal Code: _____________

Home Phone #:_______________Work Phone #:_______________ Cellular Phone #: _________________

E-mail Address: _________________________________________________________________________

Date of Birth: _________________ Sex: ______________ Provincial Health Care #:__________________

Drivers License #:________________________S.I.N. #:_________________________________________

ACCIDENT DETAILS:

Motor Vehicle Accident Date:___________________ Time of day:_______________ _________________

Details of the accident:____________________________________________________________________

______________________________________________________________________________________

Were you the driver, a passenger, or a pedestrian in this accident?__________________________________

Year, make, model of vehicle you were in:____________________________________________________

Vehicle owner’s name and address:__________________________________________________________

If occupant in the vehicle, were you wearing a seatbelt: ______ If yes, Lap & Shoulder belt___ Lap belt ___

If a passenger, your position:___front right____front middle____rear left____rear middle____rear right___

Did you hit any part of your body within the vehicle during the accident?____________________________

If yes, describe:__________________________________________________________________________

Were you in the course of employment at the time of the accident?_________________________________

INJURY DETAILS:

Describe injuries sustained in the accident:____________________________________________________

______________________________________________________________________________________

Were you taken to the hospital?_____ - If Yes-specify hospital____________________________________

By ambulance? ________

What Medical Doctor are you now seeing?_____________________________Phone #:________________

Doctor’s Office Address:__________________________________________________________________

Is this your regular doctor?_____ - If no, who is your regular Doctor:__________________________

Automobile Accident Benefits Proof Of Claim Form

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