FSRA | SABS Forms – Death and Funeral Benefits Application (OCF-4)

Death and Funeral Benefits Application (OCF-4) – SABS

The Death and Funeral Benefits Application (OCF-4) form is used by or on behalf of the spouse, dependants, and any other individuals entitled to claim death and funeral benefits following an accident. This form must be filled out clearly and must include a copy of the deceased’s death certificate. If multiple individuals are claiming benefits, they can apply either together or separately. The OCF-4 form is applicable for accidents that occurred on or after January 1, 1994.

The document must be completed and submitted to the appropriate insurance claims office, along with all required attachments and original receipts for expenses claimed.

The OCF-4 form is necessary for claiming benefits following the death of an individual due to an accident. This guide will assist you in accurately completing the form.

Step-by-Step Instructions

Deceased’s Information

1. • Last Name: Enter the deceased’s last name.
   • First Name and Initial: Enter the deceased’s first name and initial.
   • Marital Status: Check the appropriate box (Single, Married, Common-law, Separated, Divorced, Widow(er)).
   • Address, City, Province, Postal Code: Fill in the deceased’s full address.
   • Were there dependants at the time of death: Check ‘Yes’ or ‘No’. If ‘Yes’, indicate the number of dependents.
   • Death Certificate attached: Check ‘Yes’ if a death certificate is attached; otherwise, check ‘No’.

Important Dates

1. • Birth Date: Enter the deceased’s date of birth in YYYYMMDD format.
   • Date of Accident: Enter the date of the accident in YYYYMMDD format.
   • Date of Death: Enter the date of death in YYYYMMDD format.

Survivor Information

1. • Applicant 1
     • Last Name, First Name, and Initial: Enter your name.
     • Address, City, Province, Postal Code: Fill in your full address.
     • Relationship to Deceased: Check the box that describes your relationship (Spouse, Parent, Guardian, Dependent, Former spouse entitled to support, Other person on whom the deceased was dependent).
     • Contact Information: Enter your home, work, and fax numbers with area codes.
   • Applicant 2 and 3: Follow the same steps as for Applicant 1 if there are additional applicants. Attach additional sheets if necessary.

Funeral Expenses

1. • Claim Number and Policy Number: Enter the insurance claim and policy numbers.
   • Date of Accident: Enter the date of the accident in YYYYMMDD format.
   • Receipt Information
     • For each expense, provide the date (YYYYMMDD), description of the service, and name of the supplier or provider.
     • Enter the amount claimed for each service.
     • Total Payment Requested: Sum the amounts and enter the total.
     • Details of Missing Bills or Receipts: Provide explanations for any missing receipts.

Certification and Signature

1. • Applicants 1, 2, and 3
     • Name of Applicant or Substitute Decision Maker: Print your name.
     • Signature of Applicant or Substitute Decision Maker: Sign the form.
     • Date: Enter the date you signed the form in YYYYMMDD format.

Final Steps

• Double-check all entered information for accuracy.
• Ensure all required documents, including the death certificate and original receipts, are attached.
• Submit the completed form and attachments to the appropriate insurance claims office.

Note: Providing false or misleading information is an offence under the Insurance Act and the federal Criminal Code. Ensure all information is accurate and truthful to avoid legal consequences.