Ocf 2

Return this form to:
Employer's Confirmation Form

(OCF-2)
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 First Name and Initial Gender

Applicant Male Female
Information Address
City Province Postal Code
Birth Date (YYYYMMDD) Home Telephone Work Telephone
Name of Insurance Company
Address
Name of Policyholder Policy Number
Part 2 I authorize my employer to disclose to my insurance company or its authorized representative, any relevant information about my
Authorization 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) Signature of Applicant or Substitute Decision maker Date (YYYYMMDD)
Part 3 Employed Self-Employed

What Salary To my employer or former employer: If you are or were self-employed at any time during the four
I was involved in an automobile accident on: weeks before the accident, please consider yourself the
Information is employer for the purpose of completing this form.
Needed (YYYYMMDD) I was self-employed four weeks before the accident and I
designate the following time period to be used to calculate my
income (check one  and proceed to part 4).
To process my application, my insurance company needs 52 weeks (YYYYMMDD)
information about my salary for the following period before the From
Last
date of the accident. (If you check  both, the insurance
complete
company will determine which period provides the highest
fiscal year (YYYYMMDD)
benefit.)
4 weeks To
52 weeks
PRINT RESET SAVE
Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-2

FSCO (1003E.1) Page 1 of 3
The rest of this form must be completed by your employer or former employer.
Part 4 What was the applicant's actual gross income for the period before the accident date checked  above? If the employee worked
Applicant's only part of the period, list the gross income received from you during the period.
Income Gross Income Last 4 Weeks Before Accident
Gross Income for Last 52 Self-Employed:
Weeks Before Accident Gross Income
Week 1 Week 2 Week 3 Week 4 No. of Weeks Gross
additional Worked Income
sheets attached
Salary
Tips, Commissions
Other Monetary
Compensation
Total
Was the applicant absent from work for any time during the period checked () in Part 3?
Yes (Give details below) No
Are there any other types of compensation available from the employer?
Yes (Give details below) No
Part 5 To your knowledge, is the applicant eligible to receive the following benefits?
Other Benefits Income Continuation Benefit (short- Insurance Company Policy No.
term or long-term disability plan) No Yes
Supplementary Medical, Insurance Company Policy No.

Rehabilitation or Attendant Care No Yes
Benefits
Did applicant use sick credits following
Sick Leave No Yes No Yes
the auto accident?
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
Part 6 (YYYYMMDD) (YYYYMMDD) Latest Job Title

Date of
From To
Employment Employment
Details (YYYYMMDD) (YYYYMMDD)
additional Last Date Worked: Date of Return to Work (if applicable)
sheets attached
Brief Job Description
Essential Tasks of Job (Attach physical demand analysis if available):
Type of Employment Full-Time Part-Time Casual Seasonal
Part 7 Company Name Contact Person

Employer
Information Address Tax Reg. # or Business Identification Number (BIN)
Telephone Number Fax Number
PRINT RESET SAVE

Part 8 I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.
Signature
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. Regulated sectors may be subject to an examination or inquiry
about matters in connection with a licence and or unfair or deceptive act or practice. Non-compliance with applicable regulations
may result in enforcement actions ranging from an administrative monetary penalty to prosecution under the Provincial Offences
Act.
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.
Signature of Employer: Date (YYYYMMDD)
Employer Name: (Please print) Title
PRINT RESET SAVE


Ocf 2

Uploaded by

Copyright:

Available Formats

Ocf 2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ocf 2

Uploaded by

Copyright:

Available Formats

Return this form to:

Employer's Confirmation Form

Part 1 Last Name First Name and Initial Gender

City Province Postal Code

Birth Date (YYYYMMDD) Home Telephone Work Telephone

Name of Insurance Company

City Province Postal Code

Name of Policyholder Policy Number

Part 3 Employed Self-Employed

PRINT RESET SAVE

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-2

Supplementary Medical, Insurance Company Policy No.

Is the applicant a member of a union? No Yes

Part 6 (YYYYMMDD) (YYYYMMDD) Latest Job Title

Essential Tasks of Job (Attach physical demand analysis if available):

Type of Employment Full-Time Part-Time Casual Seasonal

Part 7 Company Name Contact Person

City Province Postal Code

Telephone Number Fax Number

PRINT RESET SAVE

Employer Name: (Please print) Title

PRINT RESET SAVE

Effective (2016-06-01) © Queen's Printer for Ontario, 2016 OCF-2

You might also like