OCF 1 and 5

Treatment Consent and Disclosure Notice

If you are injured and not yet in treatment, your insurance company, a member of the Intact group of companies ("Intact") can assist you in promptly accessing the treatment you require. We have a network of independently owned treatment facilities and clinics with the ability to quickly assess you to meet your treatment needs. Intact has arranged for thesecompanies to provide Intactclients with priority service. Intacthasno financial interest in any of hesecompanies. All are paid in accordance with the Minor Injury Guidelineor Professional Fee Guideline as published by the Financial Services Regulatory Authority of Ontario (FSRA), the regulatory body goveming accident benefits claims. Your participation is completely voluntary and if you choose not to participate yourentitlement to accident benefitsi: not affected. You do not need to make any commitment to treatment. may decline to participate at any time, and are free to choose a different treatment provider at any time. If you are concurrently involved in treatment that is similar to what is being recommended by this provider, it is your responsibility to advise this provider to avoid a duplication of services. Intact encourages you to speak to your family doctor and benefit from the experience and knowledge of your family doctor. Ihave read and understand the information above. I was provided with the opportunity to ask questions and all of my questions have been satisfactorily answered. I agree to participate in the services as provided by the provider. Iunderstand that if I decide to withdraw at any time, my present and future entitlement to accident benefits will not be adversely affected.

Participant's Name *

Signature *

Clear

Today's Date *

Date

Date of Birth (m/d/y) *

Date

Witness

Signature *

Clear

Today's Date

Date

Therapist Name

Claim Number

Policy Number

Date of Accident: (YYYYMMDO)

Date

Part 1 Applicant Information

Name

First Name and Initial Last Name

Date of Accident - Year

Date of Accident - Month

Date of Accident - Day

Address

City

Province

Postal Code

Date Of Birth - Year

Date Of Birth - Month

Date Of Birth - Day

Home Telephone

Work Telephone (With Extension)

Part 2 Insurance Company Information

Name of Insurance Company

Name of Insurance Company Representative

Address

Street Address Line 2

City

Province

Postal Code

Telephone Number

FAX Number

Part 3 Treating Health Professional

Name of Health Professional

Health Profession

Address

City

Province

Postal Code

Telephone Number

FAX Number

Part 4 Signature

I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional, social worker, or vocational rehabilitation expert properly appointed by my insurer to conduct an examination, only such information relating to my health condition and treatment received as a result of the automobile accident and any pre-existing or subsequently occurring health conditions that may be a barrier to my recovery as a result of the automobile accident, as is reasonably required for the purpose of providing treatment and determining my eligibility for benefits. This authorization is valid until my claim for Statutory Accident Benefits has been concluded or until withdraw this consent. (Please note withdrawal of this consent may impact your benefit entitlement This authorization does not apply to a consultation between my health care provider and the insurer's health professional conducting an examination. Separate express consent is required for this consultation. This consent should be in writing.

Name of Applicant or Substitute Decision Maker (please print)

Signature of Applicant or Substitute Decision Maker

Clear

Date (YYYYMMDD)

Date

Use this package to apply for benefits if you were injured in an automobile accident on or after November 1. 1996

About this Application for Accident Benefits Please note that all automobile accidents involving bodily injury must be reported to the police. Claims for certain accident benefits must be made within 7 days. Please contact your adjuster for further information

There are five forms in this package:

Application for Accident Benefits (OCF-1) Fill out this form when you are applying for benefits for the first time as a result of an accident, including if you are injured and are applying for income replacement benefits. You may be eligible for weekly benefits even if you were unemployed or retired at the time of the accident This Application for Accident Benefits form must be returned within 30 days after receiving the package. If you are unable to return it within 30 days, submit it to your insurance company anyway and explain why you were not able to complete it within 30 days. Return the original form to the insurance company and make a copy for your records. Employer's Confirmation of Income (OCF-2) If the insurance company asks you to, please give this form to your employer. This form is completed by you or your representative and by your employer. If you had more than one employer during the past 52 weeks, it is necessary for each employer to complete a separate form. Your insurance company may ask for other proof of income. Disability Certificate (OCF-3) If the insurance company asks you to, please fill out the first section and give this form to your health practitioner (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician, physiotherapist, speech-language pathologist or psychologist This form is completed by you or your representative and by your health practitioner. Permission to Disclose Health Information (OCF-5) If the insurance company asks you to, please complete this form. The insurance company requires your medical information in order to correctly determine your eligibility for benefits. Health professionals require your written permission to disclose this information to the insurance company. Treatment Confirmation Form (OCF-23) This form must be completed to confirm treatment received under the Minor Injury Guideline for accidents that occurred on or after September 1. 2010. There are exceptions. Please contact your insurance company to find out if this form is required.

After the insurance company reviews your complete application package, you will be contacted about the benefits you are entitled to receive. If your insurance company needs any additional information in order to process your application, they will contact you.

Warning Otfences It is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer in connection with the person's entitlement to a benefit under contract of insurance The offence is punishable on conviction by a maximum fineof $250,000 for the first offence and a maximum fine of $500,000 for any subsequent conviction It is an offence under the federal Criminal Code for anyone to knowingly make or use a false document with the intent it be acted onas genuine and the offence is punishable on conviction, by a maximum of 10 years imprisonment It is an offence under the federal Criminal Code for anyone, by deceit, falsehood or other dishonest act. to defraud or to attempt to defraud an insurance company. The offence is punishable on conviction by a maximum of 14 years imprisonment for fraud involving an amount over $5,000 or otherwise a maximum of 2 years imprisonment

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Where do I send the Application Forms?

Please follow the instructions below.

1. If You Own, Lease, or Have Regular Use of a Company Automobile

As of the date of the accident did you, your spouse or someone you are dependent on (please check all the options that apply to you)

Own an automobile? Lease or have a contract to rent an automobile for more than 30 days? Drive a company automobile which was made available for your regular use?

Drive a company automobile which was made available for your regular use?

Yes - If you checked only one, send the forms to the insurance company that insures this automobile. Yes - If you checked more than one. send the forms to the insurance company of the vehicle in which you were an occupant at the time of the accident. Yes - If you checked more than one and were not an occupant in either of the automobiles, send the forms to the insurer of either vehicle you choose No - If none apply, continue to 2.

2. If You are a Listed Driver

Are you listed as a driver on somebody's insurance policy?

Yes - If yes, send your forms to the insurance company that issued the policy you are listed on. No - If no, continue to 3.

The following categories only apply if:

You, your spouse or someone you are dependent upon does not own, lease, or regularly use a company automobile.

You are not listed as a driver on a policy.

3. Occupant of Somebody Else's Automobile. Were you an occupant of somebody else's automobile that was insured at the time of the accident?

Yes - If yes, send your forms to the insurance company that insures this automobile. No - If no, continue to 4.

4. Pedestrian or Bicyclist. Were you a pedestrian or a bicyclist struck by an automobile that was insured at the time of the accident?

Yes - If yes, send your forms to the insurance company of the automobile that struck you. No - If no, continue to 5.

5. Uninsured Automobile. Were you an occupant of an automobile that was not insured at the time of the accident?.

Yes - If yes, send your forms to the insurance company of any other automobile that was involved in the accident. No - If no, continue to 6.

6. None of the Above Apply.

If you do not have automobile insurance and no other automobile involved in the accident has automobile insurance or can be identified, you may be entitled to accident benefits from the Motor Vehicle Accident Claims Fund. Please complete the entire application package and see Part 10.

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Claim Number

Policy Number

Date of Accident: (YYYYMMDD)

Date

Name

First Name and Initial Last Name

Gender

Male Female

Marital Status

Single Seperated Married Divorced Common Law Widow(er)

Driver's Licence Number

Date Of Birth

Date

Address

City

Province

Postal Code

Is anyone dependent on you for financial support or care?

Yes, how many persons? No

How many persons?

Home Telephone

Work Telephone

Fax Number

You can be reached:

by telephone by personal visit at home at work Other

Language Spoken

E-mail:

example@example.ca

What is the best time to reach you: Day(s) of the week

Time of the day (specify a.m. or p.m. below):

Time of the day (continued):

a.m. p.m.

Part 2. Applicants Representative (if applicable).

Complete this section only if the applicant injured in the accident is deceased, is a minor, is unable to fill out the form on their own, or has retained you as their representative.

Relationship with applicant:

Parent Lawyer Guardian Other Paid Representative Other

Last Name

First Name and Initial

Address

City

Province

Postal Code

Work Telephone

Fax Number

E mail

example@example.com

Part 3. Accident Details and Health Information

Date of Accident: Year

Month

Day

Time of Accident:

a.m. p.m.

You were a:

Driver Passenger Pedestrian Other

Accident Location: Hwy. No/Street Name

City

Province

Did the accident occur while you were at work?

Yes No

Did you file a claim with the Workplace Safety and Insurance Board?

Yes No

Was the accident reported to the police?

Yes (Give details below) No

Officer Name

Badge No.

Date accident reported to the police

Year

Month

Day

Police Department/Collsion Reporting Centre

Were you charged?

No Yes (Give details)

(Give details)

Give a brief description of the accident. If you suffered any injuries as a result of the accident, describe the cause and extent of the injuries.

Were you able to return to your normal activities following the accident?

Yes No

Did you go to the hospital?

Yes (Give details) No No

(Give Details)

Did you go to see a health professional? (for example: physician, chiropractor, physiofherapist?)

Yes (Give details) No

(Give Details)

Additional sheets attached

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Part 3 Accident Details and Health Information (cont'd)

Name of Health Professional

Name of Facility

Address

City

Province

Postal Code

Has this Health Professional begun any treatment?

Yes (provide details) No

Has this Health Professional begun any treatment? (Details)

Additional sheets attached

Part 4. Details of Automobile Insurance

In order to determine which automobile insurer is responsible for paying benefits, it is necessary to know whether you have your own policy or whether you are covered by somebody else's insurance policy. To help make that determination, please complete the following:

Are you covered under any of the following automobile insurance policies?

Your own policy

Yes No

Your spouse's policy

Yes No

The policy of any person on whom you are dependent (e.g., a parent)?

Yes No

A policy that lists you as a driver (e.g., a friend)?

Yes No

Your employer's policy (e.g., company car) or spouse's employer's policy?

Yes No

A policy insuring long-term rental cars (for rentals exceeding 30 days)

Yes No

If you answered "No" to all of the above, go to B.

If you answered "Yes" to any of the above, complete the following:

Name of Policyholder

Insurance Company

Policy Number

Automobile - Make, Model, Year

Licence Plate Number

Were you an occupant of this automobile at the time of the accident?

Yes No

If you answered "Yes" to more than one box in this part, provide additional insurance details below.

Name of Policyholder

Insurance Company

Policy Number

Automobile - Make, Model, Year

Licence Plate Number

Were you an occupant of this automobile at the time of the accident?

Yes No

B.

If youchecked "No" to all of the boxes in you must send your application to the insurer of the automobile that you occupied at the time of the accident or the vehicle that struck you if you were a pedestrian or bicyclist If this automobile was not insured or was unidentified describe any other vehicle involved in the accident. Provide details below

The policy you were claiming under insures:

The vehicle was riding in at the time of the accident The vehicle that struck me as a pedestrian/bicyclist Another vehicle that was involved in the accident

Vehicle type covered by this policy:

Passenger Motorcycle Taxi/Limousine Truck Bus Snowmobile Other

Owner of the Vehicle

Home Telephone

Address

Work Telephone

City

Province

Postal Code

Automobile - Male, Model, Year

Licence Plate Number

Insurance Company

Policy Number

Name of Policyholder

Driver's Licence Number

Did you report the accident to any other insurance company?

Yes (provide details) No

Insurance Company

Type of Insurance

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Part 5. Applicant Status.

Which of the following describes your status at the time of the accident?

Employed

Employed and working Self-Employed

Not Employed

Unemployed Unemployed AND Have worked 26 weeks in the past 52 weeks Receiving Employment Insurance Benefits Retired

Other:

Student or recent graduate Caregiver

Part 6. Student Attending School

Were you attending school on a full-time basis at the time of accident or had you completed your education less than one year before the accident?

Yes (Give details below) No (Continue to Part 7)

Name of School

Date Last Attended

Year

Month

Day

Address

City

Province

Postal Code

Program and Level

Projected Date for Completion of Studies

Year

Month

Day

Are you now attending school?

Yes (Enter date below) No

Year

Month

Day

Were you able to return to school after the accident?

Yes (Enter date) No

Year

Month

Day

Were you the main caregiver to people living with you, at the time of the accident?

Yes (Complete information below) No (Continue to part 8)

Were you paid to provide care to these people?

Yes No

Name of first person being cared for

Their date of birth

Date

Are they disabled?

Yes No

Name of second person being cared for

Their date of birth

Date

Are they disabled?

Yes No

Name of third person being cared for

Their date of birth

Date

Are they disabled?

Yes No

Name of fourth person being cared for

Their date of birth

Date

Are they disabled?

Yes No

Name of fifth person being cared for

Their date of birth

Date

Are they disabled?

Yes No

Additional sheets attached

Did your injuries prevent you from performing the caregiving activities you did prior to the accident?

Yes (Explain below) No

From what date?

Year Month Day

Explanation

Additional sheets attached

At any period since the accident, were you able to return to caregiving? Year Yes(From what date?)

At any period since the accident, were you able to return to caregiving?

Yes (From what date? Enter date below) No

Year

Month

Day

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Part 8 Income Replacement Determination

Give details of your employment for the past 52 weeks. Start with your current or most recent employer. If you held more than one position with the same employer. use a separate line for each position Gross income is before taxes and deductions.

If you were self-employed during the 4 weeks prior to the accident, please consider yourself the employer for the purpose of completing this section.

Additional sheets attached

Name and Address of Most Recent Employer (1)

Date: From

Year Month Day

Date: To

Year Month Day

Position/Essential Tasks

No. of Hours Per Week

Gross Income for the period

Name and Address of Most Recent Employer (2)

Date: From

Year Month Day

Date: To

Year Month Day

Position/Essential Tasks

No. of Hours Per Week

Gross Income for the period

Name and Address of Most Recent Employer (3)

Date: From

Year Month Day

Date: To

Year Month Day

Position/Essential Tasks

No. of Hours Per Week

Gross Income for the period

Name and Address of Most Recent Employer (4)

Date: From

Year Month Day

Date: To

Year Month Day

Position/Essential Tasks

No. of Hours Per Week

Gross Income for the period

Did your injuries prevent you from working?

Yes (From what date? Enter date below) No (Continue to Part 9)

From what date?

Year Month Day

At any period since the accident, were you able to return to work since the accident?

Yes (From what date? Enter date below) No

(From what date?)

Date

The amount of your benefit is based on your past income. During which of the following periods did you have the highest average weekly income?

Last 4 woeks (not applicable for self-employed persons) Last 52 weeks Last fiscal year (self-employed only)

Part 9. Other Insurnace or Collateral Payments

Do you, your spouse or anyone you are dependent on (e.g., parents) have any other benefit plan that covers you (e.g., group or private, union, disability, medical or dental, etc)?

Yes (Give details below) No

Name of First Benefit Payor

Type of Coverage

Policy of Certificate Number

Name of Second Benefit Payor

Type of Coverage

Policy of Certificate Number

During the past 52 weeks, did you receive any income from a disability plan?

Yes (Enter dates) No

From: (date)

Year Month Day

To: (date)

Year Month Day

Total Amount Received

Are you receiving Employment Insurance Benefits?

Yes (Enter dates) No

From: (date)

Year Month Day

To: (date)

Year Month Day

Total Amount Received

Additional sheets attached

Are you receiving Social Assistance Benefits (welfare)?

Yes No

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Part 10. Motor Vehicle Accident Claims Fund

DO NOT FILL OUT UNLESS ITEMS (1) TO (5) ON PAGE 2 DO NOT APPLY AND YOU ARE APPLYING TO THE MOTOR VEHICLE ACCIDENT CLAIMS FUND

You and your representative acknowledge that you have the responsibility to investigate and apply to all potential insurers to which the applicant may have recourse BEFORE submitting an application to the Motor Vehicle Accident Claims Fund (MVACF) at 5160 Yonge Street P.O. Box 85, Toronto, ON M2N 6L9. If you have any questions about your MVACF application contact MVACF in Toronto at (416) 250-1422 or Toll Free at 1-(800) 268-7188.

You and your representative acknowledge that the application MUST INCLUDE a completed:

NOTICE OF COLLECTION OF PERSONAL INFORMATION FORM. signed and attached* Form 3 - Section 6 MVACF Application for Statutory Accident Benefits, signed and attached* Motor Vehicle Accident (Police) Report, attached.

before the applicant can make an application for the payment of accident benefits from the MVACF.

(*These forms are available at w.fsco.gov.on.ca)

I certify that have read this part and understand that this application for accident benefits is not complete until the required forms are completed, signed and provided to the MVACF.

Name of Applicant or Substitute Decision Maker (please print)

Signature of Applicant or Substitute Decision Maker

Clear

Date (YYYYMMDD)

Part 11. Direct Payment Assignment by Applicant (only applicable to applicants obtaining treatment/services from a licensed service provider)

I direct the insurer, including the Motor Vehicle Accident Claims Fund, to pay the licensed service provider directly for that portion of the approved goods and services specified on any Treatment Confirmation Form (OCF-23) and/or Treatment and Assessment Plan (OCF-18) that are not covered by extended/supplementary health insurance.

Applicants that have extended/supplementary health insurance responding to a claim may need to provide payment out of pocket before the extended/supplementary health insurer reimburses the claimant.

Applicant Initials

Part 12. Signature

TO THE INSURER, INCLUDING MVACF, TO WHOM THIS APPLICATION is BEING SUBMITTED:

I UNDERSTAND that you, and persons acting for you, will collect personal information and personal health information about me that is related to my claims for accident benefits arising out of the accident described in this application, and that all such information will be collected directly from me or from any other person with my consent.

I ALSO UNDERSTAND that you and persons acting for you will collect information about my driving record, automobile insurance policy history and automobile insurance claims history if they exist.

I ALSO UNDERSTAND that if am the holder of an automobile insurance policy, you, and persons acting for you, will collect the driving record, automobile insurance policy history and automobile insurance claims history of any listed drivers on my automobile insurance policy or other drivers whom have permitted to drive my automobile.

I ALSO UNDERSTAND that the information described above will be collected and used only as reasonably necessary for the purposes of:

Investigating my claims and processing my claims as required by law, including the Ontario Automobile Policy;
Obtaining or verifying information relating to my claims in order to determine entitlement and the proper amount of payment;
Recovering payment from insurers and others liable in law for amounts that you pay in connection with my claims;
Identifying and analyzing the nature and costs of goods and services that are provided to automobile accident victims by health care providers;
Preventing, detecting and suppressing fraud;
Compiling anonymized statistics for government agencies; and
Assessing underwriting risks and claims experience.

I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons or organizations, who may collect and use this information only as reasonably necessary to enable you or them to carry out the purposes described above:

Insurers; insurance adjusters, agents and brokers; employers; health care professionals; hospitals: accountants; financial advisors; solicitors; organizations that consolidate claims and underwriting information for the insurance industry; fraud prevention organizations; other insurance companies; the police; databases or registers used by the insurance industry to analyze and check information provided against existing information; and my agents or representatives as designated by me from time to time.

I ALSO UNDERSTAND that you, and persons acting for you, may pool this information with information from other sources and may analyze this information for the limited purpose of preventing, detecting or suppressing fraud.

I CONSENT and, if am the holder of an automobile insurance policy, declare that - have obtained consent from the listed drivers on my policy and any other drivers whom have permited to drive my automobile, to you collecting. using and disclosing this information in the manner described above, but no more of such information than is reasonably necessary to meet the legitimate purpose of such collection, use or disclosure.

I UNDERSTAND that if have any questions about this consent am free to consult with my insurance company representative or legal advisor before signing this document.

I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose this information to others without my knowledge or consent.

I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

I UNDERSTAND THAT IT IS AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance.

I FURTHER UNDERSTAND THAT IT IS AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone. by deceit, falsehood, or other dishonest act. to defraud or attempt to defraud an insurance company. This information will be used for processing payments of claims; identifying and analysing the nature, effects and costs of goods and services that are provided to automobile accident victims, by health care providers; and PREVENTING, DETECTING AND SUPPRESSING FRAUD.

To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit http://www.ibc.ca/en/privacy-terminology.asp

Name of Applicant or Substitute Decision Maker (please print)

Signature of Applicant or Substitute Decision Maker

Clear

Date (YYYYMMDD)

Date

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E mail

example@example.com

Form of Consent

OCF -5

OCF-1

Application for Accident Benefits (OCF-1)

Part 1 Applicant Information

OCF-1

OCF-1

OCF-1