Isp 2507 Form PDF Details

Are you an ISP that provides internet services to a large group of customers? If so, then the Form 2507 is something that you need to be familiar with. The 2507 form is a specific type of document released by the FCC that applies certain requirements and provisions for ISPs in order to ensure compliance with consumer protection policies. This article will provide a detailed explanation of what the Form 2507 entails, why it is important, and how your business can successfully use it when dealing with internet service providers (ISPs). Knowing your responsibilities under this regulation could make all the difference for your customer's satisfaction!

QuestionAnswer
Form NameIsp 2507 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesscisp 2507, scisp 2507 super, isp 2507 e, isp 2502b

Form Preview Example

Service

PROTECTED B (when completed)

Canada

 

QUESTIONNAIRE FOR DISABILITY BENEFITS

CANADA PENSION PLAN

1.FIRST NAME AND INITIAL

LAST NAME

SOCIAL INSURANCE NUMBER

EDUCATION

2.What was the highest grade you completed in school?

Have you attended college or university?

Yes If yes, indicate number of years and/or diploma/degree obtained.

No

3. Have you ever been involved in any technical, trade, or on the job training?

Yes If yes, provide the following details:

 

 

 

 

No

 

Dates

 

Type of program

 

Certificate obtained

 

 

 

 

 

 

 

 

 

 

 

 

WORK HISTORY (BE SURE TO INCLUDE WORK DONE IN CANADA AND/OR OTHER COUNTRIES)

EMPLOYEE

4.Have you stopped working completely?

Yes, go to question 5.

No, provide the following information:

Type of Work

Full-time

Part-time

Volunteer

Seasonal

Number of hours per day

Number of days If seasonal, explain period(s) of work per week

Salary per hour /or per day

/or per year

5.If you have stopped working completely, provide the following information:

What kind of work did you do in your most recent job?

Why did you stop working?

Date employment started

YYYY-MM-DD

Last day on the job

YYYY-MM-DD

6. Name and full address of your present or most recent employer.

SELF-EMPLOYED

7. If you are or were self-employed, provide the following information:

a) Date business started

YYYY-MM-DD

b) When did you actually stop

YYYY-MM-DD

 

 

 

 

working in the business?

 

c)Why did you stop working in the business?

d)Describe the business operation.

e)What was your involvement with the business?

Service Canada delivers Employment and Social Development Canada

programs and services for the Government of Canada.

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Disponible en français

Social Insurance Number

PROTECTED B (when completed)

SELF-EMPLOYED (CONTINUED)

f)Are you involved in the business in any way at the present time? Yes, explain your present involvement.

No, provide the following information:

Indicate what disposition has been made for the business:

sold

rented

profit sharing

Date of disposition (YYYY-MM-DD)

If no disposition has been made of the business, how does it operate now and what arrangements are you contemplating in the future?

g)What was the last year that an income tax return

on the operation of the business was filed in your name?

h)Will you declare yourself a self-employed person for income tax purposes this year?

Yes No

OTHER WORK HISTORY

IF THERE IS INSUFFICIENT SPACE TO LIST ALL YOUR OTHER TYPES OF WORK, USE THE SPACE AT THE END OF THIS QUESTIONNAIRE.

8. In the past two years, did you do any other work in addition to your

Yes If yes, provide the following details:

main job (such as part-time farming, night or other employment)?

No

 

Type of work

Number of hours Number of hours

per day

per week

Work started

YYYY-MM-DD

Last day on the job

YYYY-MM-DD

Name and full address of employer

9. Have you done any other type of work in the last five years?

Yes If yes, list the type of work and the dates. No

From

YYYY-MM-DD

To

YYYY-MM-DD

10.Because of your medical condition, did you have to do a lighter job or a different type of work?

Yes If yes, please describe.

No

11.

 

Yes If yes, give the date:

YYYY-MM

 

Has your physician told you when you can return to work?

 

 

 

12.

No

Yes If yes, answer one of the following questions:

Do you plan to return to work or seek work in the near future?

No

a) The date you plan to

YYYY-MM

return to your former

 

employer/employment

 

b) The date you

YYYY-MM

will start a

 

new job.

 

c) The date you plan

YYYY-MM

to start looking for

 

work.

 

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Social Insurance Number

PROTECTED B (when completed)

OTHER BENEFITS

13.a) If you are receiving any benefit from an insurance company, state the name of the insurance company.

b)If you are receiving any benefit from the province, have you authorized the province to send us information about your benefit?

Have you authorized the insurer to send us your medical report?

Yes No

Yes No

14. If any of your health problems are covered by Provincial workers' compensation benefits, provide details in each case.

Claim Number

 

Province or Territory

 

Year

 

Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State type of benefit you now receive.

Percentage of pension awarded

15.Have you received regular Employment Insurance benefits in the last two years?

Yes If yes, give the dates:

NO

YYYY-MM-DD

YYYY-MM-DD

From

To

 

 

YYYY-MM-DD

YYYY-MM-DD

From

To

 

 

MEDICAL INFORMATION

16. When could you no longer work because of your medical condition?

YYYY-MM-DD

 

 

 

17. Height

Weight

 

 

Right-handed

Left-handed

18.State the illnesses or impairments that prevent you from working. If you do not know the medical names, describe in your own words.

19.Describe how these illnesses or impairments prevent you from working.

20. If you have other health-related conditions or impairments, please describe them.

21. If you had to stop other activities (such as hobbies, sports or volunteer work), please explain and give dates activities ceased.

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Social Insurance Number

PROTECTED B (when completed)

22. Explain any difficulties/functional limitations you have with the following:

Sitting/Standing (How long?)

Seeing/Hearing

Walking (How long and how far?)

Speaking

 

 

Lifting/Carrying (How much and how far?)

Remembering

 

 

Reaching

Concentrating

 

 

Bending (How much?)

Sleeping

 

 

Personal needs (Eating, washing hair, dressing, etc.)

Breathing

 

 

Bowel and bladder habits

Driving a car (How long?)

 

 

Household maintenance (Cooking, cleaning, shopping and

Using public transportation

similar activities)

 

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Social Insurance Number

PROTECTED B (when completed)

INFORMATION ABOUT YOUR PHYSICIANS

23. Provide the following information about the physician who will be completing your medical report.

Physician's Full Name

 

 

 

Family Physician

Specialist (Please specify)

 

 

 

 

 

 

 

 

Address

 

 

 

 

City

 

 

 

 

 

 

 

 

Province or Territory

Country (If other than Canada)

Postal Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

YYYY-MM

 

 

 

YYYY-MM

When did you first see this physician?

 

 

When was your last visit?

 

 

 

 

 

 

 

 

 

 

 

 

What were the reasons for your visits?

24.List all other physicians you have seen in the last two years (space for two physicians is provided). If there is insufficient space to list all of your physicians, use the space at the end of this questionnaire.

a) Physician's Full Name

 

 

 

Specialty

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

City

 

 

 

 

 

 

 

 

Province or Territory

Country (If other than Canada)

Postal Code

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

YYYY-MM

 

 

 

YYYY-MM

When did you first see this physician?

 

 

When was your last visit?

 

 

 

 

 

 

 

 

 

 

 

 

Were your visits related to your present medical condition?

Yes If yes, explain the reasons for your visits.

No

b) Physician's Full Name

Specialty

 

 

Address

City

Province or Territory

Country (If other than Canada)

Postal Code

Telephone Number

When did you first see this physician?

YYYY-MM

YYYY-MM

When was your last visit?

Were your visits related to your present medical condition?

Yes If yes, explain the reasons for your visits.

No

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Social Insurance Number

PROTECTED B (when completed)

HOSPITALIZATION

25.If you have been admitted to hospital in the last two years, please provide the following information. Space for two hospitals is provided. If there is insufficient space to list all of the hospitals, use the space at the end of this questionnaire.

a) Name of hospital

Mailing address (No., Street, Apt., P.O. Box, R.R.)

City

Province or Territory

Country (If other than Canada)

Postal Code

Date YYYY-MM-DD admitted

DateYYYY-MM-DD discharged

Name of attending physician

Reason for admission and type of treatment

b) Name of hospital

Mailing address (No., Street, Apt., P.O. Box, R.R.)

City

Province or Territory

Country (If other than Canada)

Postal Code

Date YYYY-MM-DD admitted

DateYYYY-MM-DD discharged

Name of attending physician

Reason for admission and type of treatment

MEDICATION AND TREATMENT

26. List any medication you now take.

Name of medication

 

Dosage

 

How often

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.Describe other treatment you receive (such as counselling, physiotherapy).

28.If future treatments or medical tests are planned, please explain, giving dates.

29.List any medical devices you use (such as crutches, cane, artificial limb, splints, braces, wheelchair, hearing aid, heart pacemaker, ostomy apparatus).

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Social Insurance Number

PROTECTED B (when completed)

VOCATIONAL REHABILITATION

30.If considered suitable, would you consent to a vocational rehabilitation assessment?

Yes

No If no, please explain.

31.Are you presently or have you ever been involved in a rehabilitation program?

Yes If yes, please provide details.

No

DECLARATION AND SIGNATURE

The information you provide is collected under the authority of the Canada Pension Plan to determine your eligibility for a Canada Pension Plan (CPP) Disability benefit.

The Social Insurance Number (SIN) is collected under the authority of the Canada Pension Plan and in accordance with the Treasury Board Secretariat Directive on the Social Insurance Number which lists the Canada Pension Plan Regulations as an authorized user of the SIN. The SIN will be used as a file identifier, and to ensure your exact identification so that contributory earnings can be correctly applied to your record to allow benefits and entitlements to be accurately calculated.

While submitting this application is voluntary, all of the information requested is required in order to determine your eligibility for CPP Disability. If you do not provide your personal information, the Department of Employment and Social Development Canada (ESDC) may not be able to process your application or may make a decision based on the information available.

The information you provide may be shared within ESDC, with any federal institution, provincial authority or public body created under provincial law with which the Minister of ESDC may have entered into an agreement, and/or with non-governmental third parties for the purpose of administering the Canada Pension Plan, other acts of Parliament, and federal and provincial law as well as for policy analysis, research and/or evaluation purposes. The information may be shared with the government of other countries in accordance with agreements for the reciprocal administration or operation of that country's law and of the Canada Pension Plan.

The information you provide may be used and/or disclosed for policy analysis, research and/or evaluation purposes. In order to conduct these activities, various sources of information under the custody and control of ESDC may be linked. However, these additional uses and/or disclosures of your personal information will never result in an administrative decision being made about you.

Your personal information is administered in accordance with the Department of Employment and Social Development Act, the Canada Pension Plan and the Privacy Act. You have the right to the protection of, and access to, your personal information. It will be retained in Personal Information Bank ESDC PPU 140, 146 and 380. Instructions for obtaining this information are outlined in the government publication entitled Info Source, which is available at the following web site address: www.infosource.gc.ca. Info Source may also be accessed online at any Service Canada Centre.

I agree to notify the Canada Pension Plan of any changes that may affect my eligibility for benefits. This includes: an improvement in my medical condition; a return to work (full, part-time, volunteer, or trial period); attendance at school or university; trade or technical training; or any rehabilitation.

NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

Signature of Applicant or Representative

Date (YYYY-MM-DD)

Telephone Number

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Social Insurance Number

PROTECTED B (when completed)

Use this space if required. Identify the number of the question the information belongs to.

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Service

Canada

Service Canada Offices

Disability

Mail your forms to:

The nearest Service Canada office listed below.

From outside of Canada: The Service Canada office in the province where you last resided.

Need help completing the forms?

Canada or the United States: 1-800-277-9914

All other countries: 613-990-2244 (we accept collect calls)

TTY: 1-800-255-4786

Important: Please have your social insurance number ready when you call.

NEWFOUNDLAND AND LABRADOR

MANITOBA AND SASKATCHEWAN

Service Canada

Service Canada

PO Box 9430 Station A

PO Box 818 Station Main

St. John's NL A1A 2Y5

Winnipeg MB R3C 2N4

CANADA

CANADA

NOVA SCOTIA AND PRINCE EDWARD ISLAND

ALBERTA / NORTHWEST TERRITORIES

Service Canada

AND NUNAVUT

PO Box 1687 Station Central

Service Canada

Halifax NS B3J 3J4

PO Box 2710 Station Main

CANADA

Edmonton AB T5J 2G4

 

CANADA

NEW BRUNSWICK AND QUEBEC

 

Service Canada

 

BRITISH COLUMBIA AND YUKON

PO Box 250 Station A

Service Canada

Fredericton NB

E3B 4Z6

PO Box 1177 Station CSC

CANADA

 

Victoria BC V8W 2V2

ONTARIO

 

CANADA

 

 

Service Canada

 

 

PO Box 2020 Station Main

 

Chatham ON

N7M 6B2

 

CANADA

 

 

Disponible en français

SC ISP-3501-DSB (2011-11-15) E

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2. After this selection of blank fields is done, go on to enter the applicable details in all these - Number of hours per day, Number of days per week, If seasonal explain periods of work, Salary per hour, or per day, or per year, If you have stopped working, Why did you stop working, What kind of work did you do in, Date employment started, Last day on the job, YYYYMMDD, YYYYMMDD, Name and full address of your, and SELFEMPLOYED.

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4. It is time to start working on this fourth form section! In this case you will have all of these Social Insurance Number, PROTECTED B when completed, SELFEMPLOYED CONTINUED, f Are you involved in the business, Yes explain your present, No provide the following, Indicate what disposition has been, sold, rented, profit sharing, Date of disposition YYYYMMDD, If no disposition has been made of, g What was the last year that an, on the operation of the business, and OTHER WORK HISTORY fields to fill out.

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