Government of Ontario: Financial Services Commission of Ontario

Applicant
Insurer(s)
Date of Arbitration decision (yyyy/mm/dd)
Adjudicator
Arbitration or appeal file number   A

Mr.
Mrs.
Ms.

Last name
First name
Middle name
Street address
Apt./Unit
City
Province/State
Postal Code/Zip
Country
Home phone number
Work phone number Ext.
Fax number
Email address

Mr.
Mrs.
Ms.

Last name
First name
File reference number
Title
Firm name
Street address
Apt./Unit
City
Province/State
Postal Code/Zip
Country
Phone number Ext.
Fax number
Email address

Lawyer
Law Society licence number
Licensed paralegal
Law Society licence number
Not required to be licensed
Specify the type of exemption from the list of exemptions recognized in the Law Society´s by-laws

No
Yes

No
Yes

If Yes, you must inform the other party and arrange for a transcript copy to be provided to him/her
and the Director’s Delegate. State when you expect to receive the transcript. ▼

If No, briefly explain why a transcript is not needed for the Appeal. ▼

Not required to be licensed

No
Yes

If Yes, briefly explain why you are asking for a Stay.
Your reasons should be as complete as possible. ▼

Extra sheets attached

No
Yes

If Yes, briefly explain why you should be permitted to appeal a preliminary or interim order.
Your reasons should be as complete as possible. ▼

Extra sheets attached

Applicant
Representative

Name (please print)
Title