General Accident Benefits

    Claim Number:*

    Referral Source

    Name:*

    Email:*

    Title:

    Company:*

    Phone:*

    Ext:

    Fax:*

    Address:*

    City:*

    Province:*

    Postal Code:*

    Principle Insurer:

    Claimant Information

    Salutation:

    First Name:*

    Last Name:*

    Address:*

    City:*

    Province:*

    Postal Code:*

    Home Phone:*

    Other Phone:

    Date Of Birth:


    Date Of Injury:*


    Legal Information

    Legal representative?*

    Name:

    Title:

    Company:

    Phone:

    Fax:

    Address:

    City:

    Province:

    Postal Code:

    Medical Information

    Injuries (Please include all details):

    Treating Physician:

    Address:

    City:

    Province:

    Postal Code:

    Employment Information (If Applicable)

    Employer Name:

    Contact:

    Address:

    City:

    Province:

    Postal Code:

    Job Title/Occupation:

    Phone:

    Fax:

    Benefits Claimed

    Please Specify

    Independent Examinations - Assessment Type

    Please 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.

    Other Specialty/Expertise

    Other Options

    Diagnostic Testing (MRI's etc.)

    Executive Summary Of Multi-Disciplinary Assessment Opinions

    Other:

    Transportation:

    Interpreter Required:

    Language:

    Referral Questions

    Attach File

    Evolve Standard Questions (Check all that apply)

    What is the diagnosis?

    Use - Is the diagnosis an aggravation of a pre-existing condition or solely the direct result of this accident?

    Use - 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 - Please outline any objective organic pathology to substantiate subjective complaints.

    Use - What is the claimant’s prognosis?

    Use - Please identify the recovery made to date.

    Use - Please comment on any other information pertinent to this case.

    Use - Do you feel that you have had adequate information provided to you to accurately conclude your assessment opinion?

    Use - Q9. Treatment Plan (OCF-18) Review
    Are 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 - Please provide a detailed rationale and supporting evidence with your response

    Use -
    Does the claimant’s injury meet the definition of a Minor Injury as defined by the SABS?

    Use - Subject to the above, does the claimant’s treatment fall within the Minor Injury Guideline (MIG)?

    Use - 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 - If yes to the above, please provide your recommendations for treatment or assistance to manage these needs.

    Use -
    Does 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 -
    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 -
    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 -
    Does 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 - If yes, do you have any recommendations to assist in facilitating a return to care-giving activities?

    Use -
    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 -
    Does the claimant suffer a substantial ability to complete his/her pre MVA housekeeping and home maintenance activities?

    Use - 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 -
    Does the claimant currently suffer from a catastrophic impairment in accordance with the definition detailed in the (OCF-19) in question?

    Use - 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.