OCF-1: Application for Accident Benefits

What is the form for income replacement benefits in Ontario?

The OCF-10 form is used to apply for Ontario statutory accident benefits. This form is used to select the right benefit, based on your financial needs and your employment status. Many people do not understand the powerful impact of a properly completed OCF-10 form.

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Election Of Benefits Ocf 10 Which One To Choose Form

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Return this form to Election of Income Replacement Non-Earner or Caregiver Benefit OCF-10 Use this form for accidents that occur on or after November 1 1996 Claim Number Policy Number Date of Accident YYYYMMDD Although you may be eligible for the Income Replacement Benefit Non-Earner Benefit and/or the Caregiver Benefit you can only receive one of these benefits. You must choose which benefit you wish to receive. Please note that your choice of benefits cannot be changed after this form has been submitted to the insurance company unless the injury is determined to be catastrophic. If you need help in choosing the benefit please contact your insurance company representative immediately. Return this form to Election of Income Replacement Non-Earner or Caregiver Benefit OCF-10 Use this form for accidents that occur on or after November 1 1996 Claim Number Policy Number Date of Accident YYYYMMDD Although you may be eligible for the Income Replacement Benefit Non-Earner Benefit and/or the Caregiver Benefit you can only receive one of these benefits. You must choose which benefit you wish to receive. Please note that your choice of benefits cannot be changed after this form has been submitted to the insurance company unless the injury is determined to be catastrophic* If you need help in choosing the benefit please contact your insurance company representative immediately. Return this form no later than 30 days from the day you received it. Make a copy for your own records. Please print clearly. Part 1 Applicant Information Last Name First Name and Initial Gender Male Female Address City Province Postal Code Birth date yyyy/mm/dd Home Telephone Work Telephone Ext Part 2 Benefit Election I choose to receive the following benefit Part 3 Signature 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 my 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. I further understand that the use and disclosure of information contained on this form is subject to the terms described on my Application for Accident Benefits. Income Replacement Benefit Non-Earner Benefit Name of Applicant or Substitute Decision Maker please print Caregiver Benefit Signature of Applicant or Substitute Decision Maker Date yyyy/mm/dd SAVE Effective 2010-09-01 FSCO 1228E Page 1 of 1. You must choose which benefit you wish to receive. Please note that your choice of benefits cannot be changed after this form has been submitted to the insurance company unless the injury is determined to be catastrophic* If you need help in choosing the benefit please contact your insurance company representative immediately. Return this form no later than 30 days from the day you received it. Make a copy for your own records.

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