General Accident Benefits Returning customer?* Yes NoEnter Email:* Has any information changed?* Yes No Continue Would you like to save your information for next time?* Yes NoYour InformationName:* Email:* Adjuster's Name:* Title: Company:* Phone:* Ext: Fax:* Address:* City:* Province:* ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewan Postal Code:* Principle Insurer:* Save OntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland and LabradorMichiganClaim Number:* Referral SourceName:* Email:* Title: Company:* Phone:* Ext: Fax:* Address:* City:* Province:* ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewanPostal Code:* Principle Insurer: Claimant InformationSalutation: ---Mr.Mrs.MissMs.First Name:* Last Name:* Address:* City:* Province:* ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewanPostal Code:* Home Phone:* Other Phone: Date Of Birth: ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---12345678910111213141516171819202122232425262728293031 Date Of Injury:* ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember ---12345678910111213141516171819202122232425262728293031 Legal InformationLegal representative?* YesNoName: Title: Company: Phone: Fax: Address: City: Province: ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewanPostal Code: Medical InformationInjuries (Please include all details): Treating Physician: Address: City: Province: ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewanPostal Code: Employment Information (If Applicable)Employer Name: Contact: Address: City: Province: ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNova ScotiaNunavutOntarioP.E.I.QuebecSaskatchewanPostal Code: Job Title/Occupation: Phone: Fax: Benefits ClaimedPlease Specify Independent Examinations - Assessment TypePlease select from the following listing of services and disciplines. If there is a service or discipline not otherwise indicated, please use the "other specialty/expertise" text box to type in your request or call us at 1.866.432.7211, fax us at 519.432.7522 or email us. CardiologyChiropracticDental/OralENTFamily Medicine/GPFunctional(FAE/FCE)General SurgeryInfectious DiseasesInternal MedicineErgonomicLabour Market SurveyPhysical Demands AnalysesForm 1Massage TherapyNeurologicalNeuropsychiatricNeuropsychologicalNeurosurgeryOccupational TherapyOncologyOphthamologyOrthopaedicPsycho-VocationalOccupational Therapy AssessmentDiagnostic Testing (MRI's etc.)PhysiatryPhysiotherapyPsychiatricPsychologicalRespirologyRheumatologySocial WorkerUrologyTransferable SkillsVocationalJob Site AnalysisOther AssessmentOther Specialty/Expertise Other OptionsDiagnostic Testing (MRI's etc.)Executive Summary Of Multi-Disciplinary Assessment OpinionsOther: Transportation: ---YesNoTo Be DeterminedInterpreter Required: ---YesNoLanguage: ---AfrikaansAkanAlbanianASLArabicArmenianAssyrianAshantiAzerbaijaniBengaliBosnianBurmeseBulgarianCambodianCantoneseCatalanChineseCreoleCroatianCzechDanishDariDinkaDutchEnglishEstonianEweFantiFarsiFinnishFlemishFrafraFrenchFuchowFukieneseGaGermanGreekGujaratiHakkaHausaHebrewHakkaHindiHungarianIboIlocanoIndonesianItalianJapaneseKatchiKermanjiKoreanKurdishKwaLaoLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMandarinMarathiNorwegianPilipinoPersianPolishPortuguesePunjabiPushtuRomanianRussianSerbianShanghaiSinghaleseSlovakSlovenianSomaliSpanishSwahiliSwedishTagalogTaiwaneseTamilTeluguThaiTigrinyaToisanTurkishTwiUkrainianUrduVietnameseYiddishYorubaZuluReferral QuestionsAttach HereWill send with Medical FileUse Evolve Standard QuestionsAttach File Choose a FileEvolve Standard Questions (Check all that apply)Use - Q1. What is the diagnosis?Use - Q2. Is the diagnosis an aggravation of a pre-existing condition or solely the direct result of this accident?Use - Q3. If the diagnosis is an aggravation of a pre-existing condition, has the Claimant recovered to his/her pre-accident status? If not, please estimate the time such recovery might take.Use - Q4. Please outline any objective organic pathology to substantiate subjective complaints.Use - Q5. What is the claimant’s prognosis?Use - Q6. Please identify the recovery made to date.Use - Q7. Please comment on any other information pertinent to this case.Use - Q8. Do you feel that you have had adequate information provided to you to accurately conclude your assessment opinion? Use - Q9. Treatment Plan (OCF-18) ReviewAre the goods and services, contemplated in the (OCF-18) in question, reasonable and necessary as a direct result of injuries sustained in the accident?Use - Q10. Please provide a detailed rationale and supporting evidence with your responseUse - Q11. Minor Injury Guideline Does the claimant’s injury meet the definition of a Minor Injury as defined by the SABS?Use - Q12. Subject to the above, does the claimant’s treatment fall within the Minor Injury Guideline (MIG)?Use - Q13. Is there a documented pre-existing condition, and if so, does the documented pre-existing condition prevent the claimant from achieving maximal recovery from the accident related impairment if limited to the medical and rehabilitation limits of $3500.00? Use - Q14. If yes to the above, please provide your recommendations for treatment or assistance to manage these needs. Use - Q15. Income Replacement Benefit- Pre 104Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a substantial inability to engage in the essential tasks of their pre-accident employment?Use - Q16. Income Replacement Benefit- Post-104 Week Entitlement Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a complete inability to engage in employment for which they are reasonable suited by education, training or experience?Use - Q17. Non-earner Benefit Does the claimant suffer from a complete inability to carry on a normal life as a direct result of injuries sustained in the accident?Use - Q18. Caregiver BenefitDoes the claimant suffer a substantial inability to engage in the care-giving activities in which he or she engaged at the time of the accident?Use - Q19. If yes, do you have any recommendations to assist in facilitating a return to care-giving activities?Use - Q20. Attendant Care Benefit Does the claimant suffer from an impairment as a direct result of injuries sustained in the accident that results in the need for attendant care assistants? Please complete a form 1 to detail the level of assistance required in accordance with the SABS regulations.Use - Q21. Housekeeping & Home Maintenance Benefit Does the claimant suffer a substantial ability to complete his/her pre MVA housekeeping and home maintenance activities?Use - Q22. Please advise us of any complications or extenuating circumstances which may be prolonging the disability, thereby preventing a return housekeeping and home maintenance activities.Use - Q23. Catastrophic Impairment (OCF-19) ReviewDoes the claimant currently suffer from a catastrophic impairment in accordance with the definition detailed in the (OCF-19) in question?Use - Q24. Did the claimant sustain a catastrophic impairment, as defined by the SABS, as a direct result of the accident?Print Form*If you wish to print this form, please print before submitting.