Auto Insurance Claims Forms (OCF Forms)

OCF-1: Application for Accident Benefits Form

• Effective as of July 1, 2011 (PDF) Size: ## kb​
• Effective as of September 1, 2010 (PDF) Size: 318 kb​
• Effective as of May 1, 2007 (PDF) Size: 304 kb​
• Effective as of March 1, 2006 (PDF) Size: 75 kb​
• Effective as of December 1, 2004 (PDF)  Size: 126 kb​

 OCF-3: Disability Certificate

• Effective as of May 1, 2007 (PDF) Size: 53 kb​
• Effective as of March 1, 2006 (PDF) Size: 56 kb​
• Effective as of December 1, 2004 (PDF) Size: 143 kb​

OCF-4: Death and Funeral Benefits Application

• Effective as of December 1, 2004 (PDF) Size: 94 kb​

OCF-5: Permission to Disclose Health Information

• Effective as of May 1, 2007 (PDF) Size: 23 kb​
• Effective as of March 1, 2006 (PDF) Size: 24 kb​
• Effective as of December 1, 2004 (PDF) Size: 76 kb​

OCF-6: Expenses Claim Form

• Effective as of December 1, 2004 (PDF) Size: 98 kb​

OCF-9: Explanation of Benefits Payable by Insurance Company 

NB: Discontinued as of September 1, 2010. 

• Effective as of December 1, 2004 (PDF) Size: 83 kb​

OCF-10: Election of Income Replacement, Non-Earner or Caregiver Benefit

• Effective as of December 1, 2004 (PDF) Size: 84 kb​

OCF-12: Activities of Normal Life

NB: Discontinued as of September 1, 2010.

• Effective as of November 1, 1996 (PDF) Size: 103 kb​

OCF-18: Treatment and Assessment Plan

• Effective September 1, 2010 (PDF) Size: 145 kb​
• Effective as of January 7, 2008 (PDF) Size: 177 kb​
• Effective as of May 1, 2007 (PDF) Size: 93 kb​
• Effective as of March 1, 2006 (PDF) Size: 89 kb​
• Effective as of December 1, 2004 (PDF) Size: 157 kb​

OCF-19: Application for Determination of Catastrophic Impairment

• Effective as of May 1, 2007 (PDF) Size: 38 kb​
• Effective as of March 1, 2006 (PDF) Size: 43 kb​
• Effective as of December 1, 2004 (PDF) Size: 94 kb​

OCF-21: Auto Insurance Standard Invoice

• Effective September 1, 2010 (PDF) Size: 197 kb​
• Effective as of January 7, 2008 (PDF) Size: 230 kb​
• Effective as of April 2, 2007 (PDF) Size: 104 kb​
• Effective as of March 1, 2006 (PDF) Size: 118 kb​
• Effective as of December 1, 2004 (PDF)  Size: 189 kb​

OCF-22: Application for Approval of an Assessment or Examination

NB: Discontinued as of September 1, 2010.

• Effective as of May 1, 2007 (PDF) Size: 90 kb​
• Effective as of March 1, 2006 (PDF) Size: 78 kb​
• Effective as of December 1, 2004 (PDF) Size: 157 kb​

OCF-23: Treatment Confirmation Form

• Effective September 1, 2010 (PDF) Size: 155 kb​
• Effective as of January 7, 2008 (PDF) Size: 66 kb​
• Effective as of March 1, 2006 (PDF) Size: 68 kb​
• Effective as of December 1, 2004 (PDF) Size: 147 kb​

OCF-24: Minor Injury Treatment Discharge Report  

• Effective as of October 1, 2007 (PDF) Size: 72 kb​
• Effective as of December 1, 2004 (PDF) Size: 126 kb​

Settlement Disclosure Notice

• Effective as of September 1, 2010 (PDF) Size: 49 kb​
• Effective as of October 1, 2003 (PDF) Size: 91 kb​
• Final Settlement of a Statutory Accident Benefits Claim - Bill 164 (PDF) Size: 24 kb​
• Final Settlement of a Statutory Accident Benefits Claim - Bill 68 (PDF) Size: 22 kb​

Form 1: Assessment of Attendant Care Needs

• Until August 31, 2010, use this form for accidents occurring on or after March 31, 2008 (PDF) Size: 184 kb​
• Use this form for accidents occurring on or after February 1, 2007 and before March 31, 2008 (PDF) Size: 144 kb​
• Use this form for accidents occurring on or after March 1, 2006 and before February 1, 2007 (PDF) Size: 176 kb​
• Use this form for accidents occurring on or after October 1, 2003 and before March 1, 2006 (PDF)  Size: 269 kb​