Dispute Resolution Services Forms

Effective August 1, 2011, FSCO’s Dispute Resolution Forms A and B have been revised to reflect recent amendments to the Statutory Accident Benefits Schedule – Effective September 1, 2010. Forms A , B, C, D, E, G, I, J, K, L, M and P have been amended to provide for the mandatory inclusion of email addresses of the parties’ representatives. Previous versions of these forms will not be accepted.

Please refer to Bulletin A-04/11, Revisions to the Fourth Edition of the Dispute Resolution Practice Code and Revised Forms.

If additional information is required, please contact FSCO’s Dispute Resolution Services:

For information about mediation forms call:

In Toronto: 416-590-7210 or

Toll Free: 1-800-517-2332 ext. 7210

For information about arbitration forms call:

In Toronto: 416-590-7202 or

Toll Free: 1-800-517-2332 ext. 7202

For information about appeal forms call:

In Toronto: 416-590-7222 or

Toll Free: 1-800-517-2332 ext. 7222

Consent to Extend Time for Mediation/Request for a Failed Report of Mediator Form Size: ## kb Size: ## kb

(Released: December, 2012)

Consent to Fail

Where parties have made genuine efforts to resolve a dispute without any success and feel that there is no reasonable prospect of resolution if a mediation meeting were to take place, they may jointly request FSCO to fail the mediation by completing the Consent to Fail Mediation Form.

Upon receipt of properly completed form, FSCO will assign your request to a mediator for a paper review and a Report of Mediator will be issued as appropriate.

Consent to Fail Mediation Form Size: ## kb Size: 50 kb. Size: ## kb HTML form

When completing the form, parties must:

List the issues in dispute.

Provide confirmation that genuine efforts were made to resolve the dispute and that there is no reasonable prospect of a resolution.

Include the following signatures:

claimant;

witness for the claimant;

claimant representative;

witness for the claimant representative;

insurance representative; and,

witness for the insurance representative.

The completed and signed form and any relevant supporting documents should be sent by mail or fax to:

Financial Services Commission of Ontario

Dispute Resolution Services

Mediation Unit

5160 Yonge Street, 14th floor, Box 85

Toronto ON M2N 6L9

Fax: (416) 590-7077