CL22 (042019) Insurance Claim Application
Insurance Claim Application
Return To ICBC
PO BOX 2121, STN TERMINAL
VANCOUVER BC V6B 0L6
Fax 1-877-686-4222
CLAIM NUMBER ADJUSTER NAME ADJUSTER NUMBER TELEPHONE NUMBER TOLL FREE NUMBER
APPLICANT'S NAME HOME PHONE PRIMARY EMAIL ADDRESS
ADDRESS BUSINESS PHONE ALTERNATE EMAIL ADDRESS
DATE OF LOSS (ddmmmyyyy) DATE OF BIRTH (ddmmmyyyy) DRIVER'S LICENCE NUMBER MARITAL STATUS GENDER
Male Female Unspecied
PERSONAL HEALTH NUMBER
I was (select one): Driver Passenger Bicyclist Pedestrian
DESCRIBE YOUR INJURIES AND SYMPTOMS YOU ARE EXPERIENCING TRANSPORTED BY AMBULANCE
Yes No
DESCRIBE ANY PRE-EXISTING INJURY
FAMILY DOCTOR'S NAME FAMILY DOCTOR'S PHONE
TREATING DOCTOR'S NAME TREATING DOCTOR'S PHONE
OTHER MEDICAL INSURANCE PLANS
Yes No
INSURANCE AND PLAN NO. (including plans you have from employment, travel, private and/or through your spouse/parent)
OTHER DISABILITY INSURANCE PLANS
Yes No
INSURANCE AND PLAN NO. (including STD, LTD, wage loss replacement plan, private plan)
CURRENT STATUS
Retired Student Employed Homemaker Unemployed
Provide employment history details for the 12 month period preceding the accident to determine benefit eligibility
OCCUPATION 1 EMPLOYER/ORGANIZATION NAME
EMPLOYER ADDRESS EMPLOYER PHONE NUMBER
EMPLOYMENT START DATE EMPLOYMENT END DATE EMPLOYMENT TYPE
Full Time Part Time Casual Self-employed Seasonal worker
UNABLE TO WORK
Yes No
ANTICIPATED LENGTH OF TIME OFF (if any) GROSS EARNINGS
$
Hourly Weekly Monthly
OCCUPATION 2 (if applicable) EMPLOYER/ORGANIZATION NAME
EMPLOYER ADDRESS EMPLOYER PHONE NUMBER
EMPLOYMENT START DATE EMPLOYMENT END DATE EMPLOYMENT TYPE
Full Time Part Time Casual Self-employed Seasonal worker
UNABLE TO WORK
Yes No
ANTICIPATED LENGTH OF TIME OFF (if any) GROSS EARNINGS
$
Hourly Weekly Monthly
LIST ANY ADDITIONAL EMPLOYMENT INFORMATION (please attach additional pages if necessary)
WERE INJURIES SUSTAINED IN THE COURSE OF EMPLOYMENT?
Yes No
IF YES, HAVE YOU APPLIED FOR WCB BENEFITS?
Yes No
IF NO, HAVE YOU APPLIED FOR EI BENEFITS?
Yes No
Information collected on this form is done so in accordance with Section 26 of the Freedom of Information and Protection of Privacy Act and Section 9 of the Insurance
Corporation Act. This information will be used primarily in the evaluation and settlement of your current claim. There is also the possibility it will be referenced on future claims you
may have. Questions about the collection of this information may be directed to your adjuster, or call 604-661-2800 or contact the Privacy & FOI department at 151 W. Esplanade
North Vancouver, BC V7M 3H9.
The above information is provided along with related medical information as a basis for my insurance claim and is true and complete. I agree to advise ICBC of any information or
changes that may affect my claim. I understand that it is an offence to provide false or misleading information.
WITNESS TO APPLICANT'S SIGNATURE APPLICANT/PARENT GUARDIAN'S SIGNATURE DATE
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