Quick Claim – i-Claims

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What are you reporting today? *

How would you describe your injury *

Minor Injury (No Medical Assistance Needed)

Severe Injury (Medical Assistance Needed)

Near Fatal/Catastropic Injury (Continuous Medical Assistance Needed)

Please select the type of injury

Are you Resident of Ontario, Canada *

Yes

Sorry, we are currently not able to service outside Province of Ontario, Canada

I am reporting for *

Self

Authorised Person

Applicant Personal Information

First Name

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Middle Name

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Last Name *

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Phone *

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Email *

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Gender *

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Marital Status

Authorised Person Information

First Name

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Middle Name

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Last Name *

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Email *

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Phone *

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Relationship *

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Legal Disclaimer

Are you currently being represented by any legal entity?

Yes

Legal Firm Name *

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Phone Number

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Terms & Condition to Transfer Retainership

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