Automobile Accident Benefits Proof Of Claim Form Page 2
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3CLAIM #: ___________________
Has any treatment been prescribed?____________- If yes, give details:_____________________________
______________________________________________________________________________________
Are you a student? ______ Full-time______Part-time ________, Institution:_________________________
Place of employment:__________________________Duration with employer:______Years______Months
Employer Address:_______________________________________________________________________
Occupation and duties of your job:___________________________________________________________
______________________________________________________________________________________
Number of hours worked per week?:____Hourly wage:_____Salary:______Weekly:______Monthly:_____
What days do you usually work?(check all that apply):__Mon__Tue___Wed___Thurs___Fri___Sat___Sun
Since the accident, have your job duties been affected?______________– if yes, how?
______________________________________________________________________________________
If employed, did you stop working due to this accident?___________
Date last worked:_____________________
What date did you return to work, or when do you expect to return?_________________________
If not currently employed, list prior employers over the past 12 months:
Employer: __________________________________ Employer: ________________________________
Address: ___________________________________
Address: __________________________________
Phone #:___________________________________
Phone #:__________________________________
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Period Employed: ____________________________ Period Employed: __________________________
*If you are claiming wage loss and if you are self employed, on commission, or a casual worker,
submit copies of your personal income tax records and a copy of your Revenue Canada Assessment
Notice for the prior year, including T4 slips, or Employers Verification of employment and earnings.
OTHER INSURANCE DETAILS:
Do you have any coverage for sick leave or disability benefits through your employer or a private health
plan? __________ - If yes, Insurance Company: _______________________________________________
Amount $:___________________ Per week ____________________ Per month______________________
Do you have any medical expense coverage through your employer, school, or a private health plan? _____
Does your spouse (or parents if you are a dependent) have a medical benefit plan that covers you? _______
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