Employer`s Confirmation Form

Employer's Confirmation
Form (OCF-2)
Return this form to:
Use this form for accidents that occur on or after November 1,1996.
Claim Number:
Policy Number:
Date of Accident:
(YYYYMMDD)
If your insurance company asks you to complete this form, fill in parts 1 through 3 and give the form to your employer or former employer(s)
to complete the rest. Please have each employer you listed on your Application for Accident Benefits form fill out a separate form.
Extra forms are available from your insurance company. Your employer(s) will return the form(s) directly to the insurance company.
Please print clearly.
Part 1
Last Name
Applicant
Information
Address
First Name and Initial
Gender
Male
City
Province
year
Birth
Date
month
day
Home
Telephone
Female
Postal Code
Area Code
Work
Telephone
Area Code
Name of Insurance Company
Address
Part 2
Authorization
City
Province
Name of Policyholder
Policy Number
I authorize my employer to disclose to my insurance company or its authorized representative, any relevant information about my
employment, including copies of relevant documents directly relating to my application for income replacement benefits and details
of any collateral sources of income or benefits.
Name of Applicant or Substitute Decision Maker (please print)
Part 3
What Salary
Information
is Needed
Postal Code
Date (YYYYMMDD)
Signature of Applicant or Substitute Decision Maker
Employed
To my employer or former employer:
I was involved in an automobile accident on:
Self-Employed
If you are or were self-employed at any time during the four
weeks before the accident, please consider yourself the
employer for the purpose of completing this form.
I was self-employed four weeks before the accident and I
designate the following time period to be used to calculate my
To process my application, my insurance company needs information about my salary
income (check one 9 and proceed to part 4).
for the following period before the date of the accident. (If you check 9 both, the
52 weeks
year
month
day
insurance company will determine which period provides the highest benefit.)
Last complete From
fiscal year
4 weeks
year
month
day
year
month
day
To
52 weeks
The rest of this form must be completed by your employer or former employer.
Part 4
Applicant's
Income
What was the applicant's actual gross income for the period before the accident date checked 9 above?
If the employee worked only part of the period, list the gross income received from you during the period.
Gross Income for Last
52 Weeks Before Accident
Gross Weekly Income Last 4 Weeks
Before Accident
Week 1
Week 2
Week 3
Week 4
No. of Weeks
Worked
Self-Employed: Gross
Income
Gross
Income
Salary
Tips, Commissions
Other Monetary
Compensation
Total
OCF-2 (11/04)
Page 1 of 2
Part 4
Applicant's
Income
Was the applicant absent from work for any time during the period checked ( 9 ) in Part 3?
Yes (Give details below)
No
(cont'd)
additional
sheets
attached
Part 5
Other
Benefits
Part 6
Employment
Details
additional
sheets
attached
Are there any other types of compensation available from the employer?
Yes (Give details below)
No
To your knowledge, is the applicant eligible to receive the following benefits?
Income Continuation Benefit
(short-term or long-term disability plan)
No
Yes
Supplementary Medical,
Rehabilitation or
Attendant Care Benefits
No
Yes
Sick Leave
No
Yes
Employer
Information
Signature
Insurance Company
Policy No.
Did applicant use sick credits
following the auto accident?
Yes
Is the applicant a member of a union?
No
Yes
Does or did the applicant contribute to the Canada Pension Plan or a similar plan?
No
Yes
Was a claim filed with the Workplace Safety and Insurance Board as a result of this accident?
No
Yes
year
Date of Employment
month
day
From :
year
month day
Latest Job Title
To:
year
Last Date Worked:
month
day
Date of Return to Work (if applicable)
year
month
day
Brief Job Description
Essential Tasks of Job (Attach physical demand analysis if available):
Full-Time
Part-Time
Casual
Seasonal
Contact Person
Company Name
Address
Tax Reg. # or Business Identification Number (BIN)
City
Province
Telephone
Number
Part 8
Policy No.
No
Type of Employment
Part 7
Insurance Company
Area Code
FAX
Number
Postal Code
Area Code
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.
Signature of Employer:
Employer Name: (Please print)
Date:
year
month
day
Title:
OCF-2 (11/04)
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