Form 3 Statutory Accident Benefit Schedule

Ontario Automobile Insurance Death and Funeral Payment Request

Insurer Information


1 - Identity of Deceased

Marital Status of Deceased:

2 - Identity of Person Making Claim

Making Claim as:

3 - Payment Requested

4 - Details of Expenses

Attach original receipts

Claimant's Expenses
Item Date Description of Service and Name of Service Provider Amount

5 - Deceasedís Dependents

Language Preferred:

Language Preferred:

Is there any other person who may be entitled to make a claim for these benefits?

If yes, please specify:

6 - Declaration

I certify in good faith that the information provided is true.