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OAF 1
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Ontario Application for Automobile Insurance
Owner’s Form (OAF 1)
This is your Application for Automobile Insurance.
- Check it carefully and notify your Broker/Agent of any errors or of any changes in the future.
- Retain this document for your Records.
Some of the terms used in this application are explained further below.
Insurance Company Broker/Agent
Insurance Coverages Applied For
Ontario motorists must have the following standard coverages: Liability, Accident Benefits, Uninsured Automobile
and Direct Compensation Property Damage. You may also purchase additional insurance for Loss or Damage to
the automobile and Optional Increased Accident Benefits. This is a brief explanation of the insurance coverages
available to you. For complete details consult your policy. Your Insurer will supply you with a copy of the policy if
you request it.
Liability - Provides coverage for you or other insured persons if someone else is killed or injured or their property
is damaged in an automobile incident. It will pay for legitimate claims against you or other insured persons up to
the limit of your coverage, and the cost of settling claims.
Accident Benefits - Your insurance company is obligated to explain details of Accident Benefits coverage to you.
Provides benefits that you and other insured persons may be entitled to receive if injured or killed in an automobile
accident. These benefits include: income replacement for persons who have lost income; payments to non-
earners who suffer complete inability to carry on a normal life; payment of care expenses to persons who cannot
continue to act as a primary caregiver for a member of their household; payment of medical, rehabilitation and
attendant care expenses; payment of certain other expenses; payment of funeral expenses; and payments to
survivors of a person who is killed. You may also purchase optional benefits to increase the standard level of
benefits provided in your policy.
The optional benefits your insurance company must offer are:
Increased Income Replacement - The standard level of income replacement provided in the policy ($400
per week maximum) may be increased by purchasing optional coverage so that the weekly limit is up to $600,
$800 or $1,000. All income replacement benefits are based on 70% of your gross weekly income.
Increased Medical, Rehabilitation and Attendant Care - The standard benefit pays up to $65,000 for
medical, rehabilitation and attendant care expenses with a 5 year time limit in most cases. If catastrophically
impaired, the standard benefit pays up to $1,000,000 for medical, rehabilitation and attendant care expenses.
You may purchase an optional medical, rehabilitation and attendant care benefit of $130,000 or $1,000,000.
Additional Catastrophic Impairment - You may purchase an optional catastrophic impairment benefit of an
additional $1,000,000 added to the standard medical, rehabilitation and attendant care benefit or the optional
increased medical, rehabilitation and attendant care benefit.
Caregiver Benefit, Housekeeping and Home Maintenance Expenses - The standard benefit for caregiver
benefit, housekeeping and home maintenance expenses is available only for a person who is catastrophically
impaired. You may purchase an optional benefit to provide these coverages for other impairments.
Death and Funeral - The standard level of death benefits paid to the surviving spouse and dependant of a
person who is killed ($25,000 to a surviving spouse and $10,000 to each surviving dependant) may be
doubled by purchasing this optional coverage. This coverage also increases the standard funeral expense
benefit from $6,000 to $8,000.
Dependant Care - There is no standard dependant care benefit. You may purchase an optional benefit to
receive weekly dependant care expenses of $75 for the first dependant, and $25 for each additional
dependant, up to $150 per week, for employed persons not receiving a weekly caregiver benefit.
Indexation Benefit - This optional coverage will ensure that certain weekly benefit payments and monetary
limits will be adjusted on an annual basis to reflect changes in the cost of living.
Uninsured Automobile
Provides coverage if you or other insured persons are injured or killed by an uninsured motorist or by an
unidentified (e.g. hit-and-run) driver. It also covers damage to your automobile and its contents caused by an
identified, uninsured motorist, subject to a $300 deductible.
Direct Compensation Property Damage
Provides coverage in Ontario, under certain conditions, for damage to your automobile and to property it is
carrying, when another motorist is responsible. It is called Direct Compensation because you will collect from us,
your insurance company, even though you are not at fault for the accident. There may be a deductible amount,
and this amount is either paid by you toward the cost of repairs or is deducted from the loss settlement. Higher
deductibles may reduce your premium.
Loss or Damage
Provides a selection of optional coverages for your own automobile. Payments cover direct and accidental loss of,
or damage to, a described automobile and its equipment. There is usually a deductible amount indicated for each
coverage and this amount is either paid by you toward the cost of repairs or is deducted from the loss settlement.
Higher deductibles may reduce your premium. There are four types of coverages:
Specified Perils: Covers the described automobile against loss or damage caused by certain specific perils.
They are: fire; theft or attempted theft; lightning, windstorm, hail or rising water; earthquake; explosion; riot or
civil disturbance; falling or forced landing of aircraft or parts of aircraft; or the stranding, sinking, burning,
derailment or collision of any kind of transport in, or upon which, the described automobile is being
transported.
Comprehensive: Covers a described automobile against loss or damage other than those covered by
Collision or Upset, including perils listed under Specified Perils, falling or flying objects, missiles and
vandalism.
Collision or Upset: Covers damage when a described automobile is involved in a collision with another
object or tips over.
All Perils: Combines the Collision or Upset and Comprehensive coverages.
For purposes of the Insurance Companies Act (Canada), this document was issued in the course of the insurance
company’s insurance business in Canada.
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OAF 1
Page 2 of 4
Ontario Application for Automobile Insurance
Owner's Form (OAF 1)
Policy No. Assigned
New policy
Replacing Policy No.
Company bill
Broker/Agent bill
Other (specify)
Language
English
Preferred
French
Insurance Company (Insurer)
Broker/Agent
Broker Code:
1
Applicant's Name & Primary Address
“Primary Address” means address where applicant normally resides.
Lessor (if applicable)
Name and Address
Name and Address
Postal Code
Postal Code
Phone No. Home ( ) Work ( )
Phone No. ( ) Fax ( )
2
Policy Period (all times are local times at the applicant's address shown above)
Effective Date:
Year
Month
Day
Time:
a.m.
Expiry Date:
Year
Month
Day
Time::
p.m.
at 12:01 a.m.
3
Described Automobile - Each automobile will be used primarily in the vicinity of the applicant's address, unless otherwise stated in Remarks.
Auto
No.
Model
Year
Make or Trade Name
Model
Body Type
No. of Cylinders
or Engine Size
Gross Vehicle Weight Rating
[ ] Lbs [ ] Kg
1.
2.
3.
Auto
No
Vehicle Identification No. (Serial No.)
Owned?
Leased?
Purchased/Leased
Purchase Price
(including options &
taxes)
Automobile Use (*Give details in Remarks section)
Year
Month
New?
Used?
Pleasure
Commute
One - Way
Business Use
%*(see Note 1)
Farm
Commercial*
1.
km
%
2.
km
%
3.
km
%
Auto
No.
Estimated Annual
Driving Distance
Is any automobile used for car pooling?
If Yes, give no. of Passengers and Details
Type of Fuel Used
Unrepaired Damage?
Modified/Customized
(See Note 2)
Gas
Diesel
If other, give details:
(If Yes, give details in Remarks section)
1.
km
Yes No
Yes No
Yes No
2.
km
Yes No
Yes No
Yes No
3.
km
Yes No
Yes No
Yes No
Auto
No.
Lienholder Name & Postal Address
1.
2.
3.
Is the applicant both the Registered Owner and the Actual Owner of the described automobile(s)? Yes No If No, give details in Remarks section.
Will any of the described automobiles be rented or leased to others, or used to carry passengers for compensation or hire, or haul a trailer, or carry explosives or radioactive material? Yes No
Total number of automobiles in the household or business.
4
Driver Information List all drivers of the described automobile(s) in the household or business.
Driver
No.
Name as shown on Driver's Licence
Driver's Licence Number
Date of Birth
Sex
Marital Status
Year
Month
Day
1.
2.
3.
4.
Driver
No.
Driver Training Certificate
Attached?
Date First Licensed in Canada or U.S.
(Class G or equivalent)
Other class of licence, if any
Percentage Use by Each Driver
Are any other persons in the
household or business
licensed to drive?
Do any drivers qualify for
Retiree Discount?
(See Note 3)
Class
Year
Month
Class
Year
Month
Auto. 1
Auto. 2
Auto. 3
1.
Yes No
Yes No
If yes, provide complete
details in the Remarks
section.
Yes No
2.
Yes No
Yes No
3.
Yes No
Yes No
4.
Yes No
Yes No
Special Notes:
Note 1: Business Use % - State the usual percentage of annual driving distance that is for business use. (Enter 0 if there is no business use)
Note 2: Modified/customized includes changes, other than repairs or restorations that affect the original manufacturer’s design specifications or increase
the value of the automobile. These may include, but are not limited to: engine modifications; paint changes; non-factory installed wheels, tires and
electronic accessories and equipment, etc. If you are insured for "Loss or Damage Coverage", there is a $1500 limit on non-factory installed
electronic accessories and equipment.
Note 3: Retiree Discount You may be entitled to a discount if you are the principal operator of a described automobile, are retired, have not been
employed for 26 weeks or more in the last 52 weeks, do not earn or receive income from any office or employment, are not engaged in any
professional occupation and are not operating a business. To qualify, you must be at least age 65, or receiving a pension under the Canada
Pension Plan, the Quebec Pension Plan, or a pension registered under the Income Tax Act. If you qualify, your broker or agent will ask you to sign
a declaration to confirm this.
If a driver is licensed less than 6 years in Canada, driving experience in other countries may be recognized. Attach proof of other licensing and insurance.
What are the details of the applicant's most recent automobile insurance?
Insurance Company
Policy No.
Expiry Date
Year
Month
Day
To the applicant's knowledge...
Has any driver's licence, vehicle permit etc, issued to the applicant or to any person in the household or business been suspended or cancelled in the last 6 years?
Yes No If Yes, give details in Remarks section.
Has any insurance company cancelled automobile insurance for the applicant or any listed driver in the last 3 years?
Yes No If Yes, give details in Remarks section.
During the last 3 years, has any automobile insurance policy issued to the applicant or any listed driver been cancelled or has any claim been denied for material misrepresentation?
Yes No If Yes, give details in Remarks section.
Has the applicant or any listed driver been found by a court to have committed a fraud connected with automobile insurance?
Yes No If Yes, give details in Remarks section.
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OAF 1
Page 3 of 4
5
Previous Accidents and Insurance Claims
Give details of all accidents or claims arising from the ownership, use or operation of any automobile by the applicant or any listed driver during the last 6 years. The coverages are: BI - Bodily Injury, PD -
Property Damage, AB - Accident Benefits, DCPD - Direct Compensation - Property Damage, UA - Uninsured Automobile, Coll- Collision, AP - All Perils, Comp - Comprehensive, SP - Specified Perils
Driver
No.
Auto
No
Date
Coverage Claim Paid Under
Amount Paid or Estimate
Details (Use Remarks section if necessary)
Year
Month
Day
BI
PD
AB
DCPD
UA
Coll/AP
Comp/SP
6
History of Convictions
Give details of all convictions of the applicant and any listed driver arising from the operation of any automobile in the last 3 years.
Driver
No.
Date Convicted
Details (Use Remarks section if necessary)
Driver
No
Date Convicted
Details (Use Remarks section if necessary)
Year
Month
Day
Year
Month
Day
7
Rating Information AGENT/BROKER AND COMPANY USE ONLY
Auto
No.
Class
Driving Record
Driver No.
At-Fault Claim Surcharges
Conviction Surcharges
BI
PD
AB
DCPD
Coll/AP
Princ.
Sec.
Description
%
Description
%
1.
2.
3.
Auto
No.
List Price New
Vehicle Code
Rate Group
Location
Territory
Discounts
Description and Percentage
AB
DCPD
Coll/AP
Comp/SP
1.
2.
3.
8
Insurance Coverages Applied For Read Page 1 of this form before completing this section.
Automobile 1
Automobile 2
Automobile 3
Occasional
Driver Premium
Liability
Limit (000s)
Premium
Limit (000s)
Premium
Limit (000s)
Premium
Bodily Injury
Property Damage
Accident Benefits (Standard Benefits)
Optional Increased Accident Benefits
( ) Coverage Required
Income Replacement ($600/$800/$1,000)
(up to $
per week)
(up to $
per week)
(up to $
per week)
Medical, Rehabilitation & Attendant Care
($130,000/$1,000,000)
Optional Catastrophic Impairment (additional $1,000,000
added to Standard Benefit or Optional Medical,
Rehabilitation & Attendant Care Benefit)
As stated in
Section 4 of Policy
As stated in
Section 4 of Policy
As stated in
Section 4 of Policy
Caregiver, Housekeeping & Home Maintenance
Death & Funeral
Dependant Care
Indexation Benefit (Consumer Price Index)
Uninsured Automobile
As stated in
Section 5 of Policy
As stated in
Section 5 of Policy
As stated in
Section 5 of Policy
Direct Compensation-Property Damage
This policy contains a partial payment of recovery clause for property damage
if a deductible is specified for Direct Compensation-Property Damage.
Deductible
Deductible
Deductible
Loss or Damage*
Deductible
Premium
Deductible
Premium
Deductible
Premium
Premium
Specified Perils (excluding Collision or Upset)
Comprehensive (excluding Collision or Upset)
Collision or Upset
All Perils
* This policy contains a partial payment of loss clause. A deductible applies for each claim except as stated in your policy.
Policy Change Forms (Name & No.)
Deductible/Limit
Premium
Deductible/Limit
Premium
Deductible/Limit
Premium
Premium
Family Protection Coverage -OPCF 44R Yes No
LIMIT SAME AS LIABILITY UNLESS
OTHERWISE NOTED
LIMIT SAME AS LIABILITY UNLESS
OTHERWISE NOTED
LIMIT SAME AS LIABILITY UNLESS
OTHERWISE NOTED
Total Premium Per Automobile
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OAF 1
Page 4 of 4
9
Remarks - Use this space if you have further details
Extra sheets attached.
10
Method of Payment
Type of Payment Plan
Estimated Policy Premium**
Tax
Interest
Total Estimated Cost
Amt. Paid with Application
Amount Still Due
No. of Remaining Instalments
Amount of Each Instalment
Instalment Due Date
Y
M
D
** This policy premium is estimated and subject to adjustment or confirmation by the insurer. If we issue a policy and the applicant cancels it, there may be a minimum premium
shown on your Certificate of Automobile Insurance that will not be refunded.
11
Declaration of Applicant Read this section carefully before you sign.
I understand that to qualify for a driver’s licence, drivers:
must not suffer from any mental, emotional, nervous or physical disability that significantly interferes with the driver's ability to safely drive an automobile of the class they are
licensed for;
must not be addicted to alcohol or a drug to the extent that it significantly interferes with the driver's ability to safely drive an automobile; and
must notify the Ministry of Transportation immediately if the driver becomes physically or mentally disabled to the extent that it might interfere with the driver's ability to safely drive
an automobile.
To the best of my knowledge,
all listed drivers are qualified to drive and hold a valid driver’s licence,
the details in Sections 1 to 6 and 9 are correct.
Inspection:
My Insurer may require my automobile to be inspected. If I do not co-operate with any reasonable arrangements to inspect my automobile, I understand my optional loss or damage
coverages under Section 7 may be cancelled, and any claims under that section may be denied.
Warning - The Insurance Act provides that where:
(a) an Applicant for a contract, (i) gives false particulars of the described automobile to be insured to the prejudice of the Insurer, or (ii) knowingly misrepresents or fails to
disclose in the application any fact required to be stated therein; or
(b) the Insured contravenes a term of the contract or commits a fraud; or
(c) the Insured wilfully makes a false statement in respect of a claim under the contract, a claim by the Insured, for other than such statutory accident benefits as are set out in
the Statutory Accident Benefits Schedule, is invalid and the right of the Insured to recover indemnity is forfeited.
Warning Offences
It is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an Insurer in connection with the person’s entitlement to a
benefit under contract of insurance, or to wilfully fail to inform the Insurer of a material change in circumstances within 14 days, in connection with such entitlement. The
offence is punishable on conviction by a maximum fine of $250,000 for the first offence and a maximum fine of $500,000 for any subsequent conviction.
It is an offence under the federal Criminal Code for anyone to knowingly make or use a false document with the intent it be acted on as genuine and the offence is punishable,
on conviction, by a maximum of 10 years imprisonment.
It is an offence under the federal Criminal Code for anyone, by deceit, falsehood or other dishonest act, to defraud or to attempt to defraud an insurance company. The offence
is punishable, on conviction, by a maximum of 14 years imprisonment for fraud involving an amount over $5,000 or otherwise a maximum of 2 years imprisonment.
Notice and Consent
I am applying for automobile insurance based on the information provided above. With respect to this application or any renewal or change in coverage, I authorize you to collect, use and
disclose my driving record, automobile insurance policy history and automobile insurance claims history as permitted by law for the limited purposes necessary to assess the risk, to
investigate and settle claims, and to prevent, detect and suppress fraud. If I am issued an automobile insurance policy or if I make a claim, this information may be pooled with information
from other sources and may be subject to analysis for the limited purpose of preventing, detecting or suppressing fraud. For this purpose, the information also may be disclosed to i) fraud
prevention organizations, other insurance companies and the police and ii) databases or registers used by the insurance industry to analyze and check information provided against existing
information.
I declare that I have obtained consent from the listed drivers to the collection, use and disclosure by you of their driving record, automobile insurance policy history and automobile insurance
claims history as described above, I also declare that, prior to permitting any other individuals to drive my automobile, I will obtain consent from such individuals to the collection, use and
disclosure by you of their driving record, automobile insurance policy history and automobile insurance claims history also as described above.
I understand that if I have any questions about this consent I am free to consult with my insurance company representative or legal advisor before signing this document.
To obtain further information about how your consent relates to pooling and data analytics to prevent and detect fraud please visit http://www.ibc.ca/en/privacy-terminology.asp.
Applicant's Signature
Date
12
Report of Broker/Agent
Have you bound this risk?
Yes No
Is this business new to you?
Yes No
Type of Motor Vehicle Liability
Insurance Card issued
Temp Perm None
How long have you known the
Applicant?
How long have you known the Principal Driver?
Has an inspection been completed? Yes No
Broker/Agent Signature
Date
The Applicant must receive a copy of the signed application.
A supplementary form for commercial or public use automobiles may be necessary.
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