Form 4 Statutory Accident Benefit Schedule

Ontario Automobile Insurance Application Medical or Psychological Report

Insurer Information


1 - Identity of Claimant

2 - Treating Practitioner


3 - Examination/Objective Findings

4 - Investigations/Test Results

(Include dates)

5 - Diagnosis or Classification

6 - Treatment Plan




Plan of Return Visits

7 - Duration of Disability

8 - Signature of Physician or Psychologist

The fee for completion of this form is not a health care benefit of the Ontario Ministry of Health. That fee, and the cost of any examinations not covered by the Health Insurance System, should be billed to the automobile insurer to whom this form is submitted.

Submission of a completed and signed form to the insurer constitutes a request for payment for its completion. No other invoice will be submitted.