Accident Benefits Referral

Insured’s Contact Info (only if ADS can contact)

Insurer’s Contact Info (for billing)

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General Questions

Please provide the following documentation. Please indicate explicitly if it is not available.

• OCF-1, OCF-2, and OCF-3

• Personal Tax Return, Statement of Business Activities and Notice of Assessment – Last tax year prior to the MVA and all since

• Corporate Tax Return, Schedules 1, 8, 50, 125 and Notice of Assessment – Last tax year prior to the MVA and all since

• Statutory Declaration

• Insurer’s denial of payment / eligibility

• Any other Financial documents (i.e. pay statements)

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