4. (a) If the accident caused total and irrecoverable loss of sight, hearing or speech, please indicate which:
Sight Hearing Speech
(c) Is there any possibility of improvement to the injured area? Yes No
LOSS OF VISION
(c) Please include visual acuity results and Opthalmologist report.
LOSS OF HEARING
(c) Please include Audiologist report and hearing test.
LOSS OF SPEECH
(c) Please include Speech Therapy assessment.
LOSS OF USE
5. (a) If the accident caused loss of use of leg, arm, or hand, please advise which.
Leg Arm Hand
(b) Is there any indication that the injured limb was unable to function normally prior to accident? Yes No
(d) Is there any possibility of improvement to the injured area? Yes No
(e) Please include: Hospital admittance and discharge summary, surgery report (if relevant), Range of Motion test results and
Physiotherapist / Occupational Therapist reports, consultation and progress reports, Neurologic exam (paraplegia / quadriplegia).
6. (a) Was the injury described solely responsible for the loss? Yes No
(b) Date on which loss occured. Month Day Year
(a) If known to you, please advise the vision in each eye prior to the accident.
(b) What is the best corrected vision in the affected eye(s), if any?
(a) Is there any indication that hearing was abnormal prior to accident?
(b) Level of hearing at date of loss.
(a) If known to you please advise if the insured was able to speak intelligibly prior to accident.
(b) Is insured’s speech intelligible at the present time?
(c) Please indicate what functions, if any, the injured limb is able to perform.
(b) If not, give particulars of any contributing cause or causes.
Print Name Specialty Telephone Number:
Date Signed M.D.
Address
Street City Province Postal Code
