Declaration of Post-Accident Income and Benefits (OCF-13) – SABS

The Declaration of Post-Accident Income and Benefits (OCF-13) is a crucial form used to report income and benefits received after an accident. Applicable for accidents occurring on or after January 1, 1994, this form helps insurance companies determine the appropriate amount of accident benefits you are entitled to receive. This form must be completed accurately and submitted to ensure proper processing of your accident benefits.

Filling out the OCF-13 form correctly is essential to ensure you receive the appropriate accident benefits. Follow these step-by-step instructions to complete the form:

• Applicant Information
  • Last Name, First Name, and Initial: Enter your full name.
  • Address: Provide your current mailing address, including city, province, and postal code.
  • Home Telephone: Include your area code and phone number.
  • Date of Accident: Write the date of the accident in YYYYMMDD format.

• Employment Income
  • Employment Income: Indicate if you have received any income from employment since the accident. If yes, provide the details for each employer or business.
    • Name of Employer/Business: Enter the name of your employer or business.
    • Job Title: Specify your job title.
    • Telephone Number: Include the area code and phone number of your employer.
    • Employer Contact Name: Write the name of your employer’s contact person.
    • Employed From/To: Indicate the dates you were employed in YYYYMMDD format.
    • Total Hours: Record the total hours worked.
    • Total Income Received: State the total income received in dollars.
• Private Disability Benefits
  • Indicate if you have received any private disability or income replacement benefits since the accident. If yes, provide the details.
    • Group Benefits: Mark ‘Yes’ or ‘No’ for short-term and long-term benefits.
    • Private Benefits: Mark ‘Yes’ or ‘No’ for short-term and long-term benefits.
    • Other: Specify the type of benefit if applicable.
    • Name of Insurance Company: Enter the name of the insurance company providing the benefits.
    • Name of Policyholder: State the policyholder’s name.
    • Policy/Group Certificate Number: Provide the policy or group certificate number.
    • Benefits Start Date: Enter the start date of the benefits in YYYYMMDD format.
    • Total Amount Received: Record the total amount received in dollars.

• Public Benefit Plans
  • Indicate if you have received any public benefits since the accident. If yes, provide the details.
    • CPP Disability Pension: Mark ‘Yes’ or ‘No.’
    • Workplace Safety and Insurance Board: Mark ‘Yes’ or ‘No.’
    • Employment Insurance (EI) Sick Benefits: Mark ‘Yes’ or ‘No.’
    • Other: Specify the type of benefit if applicable.
    • Claim Number: Enter the claim number.
    • Benefits Received From/To: Indicate the dates you received benefits in YYYYMMDD format.
    • Total Amount Received: Record the total amount received in dollars.

• Medical/Dental Benefits
  • Indicate if you have submitted any medical or dental receipts for expenses incurred due to the accident. If yes, provide the details.
    • Group Benefit Plan: Mark ‘Yes’ or ‘No.’
    • Private Benefit Plan: Mark ‘Yes’ or ‘No.’
    • Other: Specify the type of benefit if applicable.
    • Name of Insurance Company: Enter the name of the insurance company.
    • Name of Policyholder: State the policyholder’s name.
    • Policy Number: Provide the policy number.
    • Type of Expense: Specify the type of expense incurred.

• Certification
  • Read the certification statement carefully.
  • Signature: Sign the form to certify that the information provided is true and correct.
  • Date: Enter the date of signature in YYYYMMDD format.
  • Name of Applicant or Substitute Decision Maker: Print your name or the name of the substitute decision-maker if applicable.

Ensure all sections are completed accurately. If you need assistance, consult your insurance company or legal advisor. Return the completed form to the designated address provided by your insurer.