Ocf 2 Form PDF Details

The Employer's Confirmation Form (OCF-2) plays a crucial role for individuals involved in automobile accidents since November 1, 1996, especially when they are applying for income replacement benefits through their insurance. This document requires detailed input from both the claimant and their current or previous employers to establish the financial compensation necessary for the period of recovery. Not only does it entail personal information and employment history, but it also includes authorization for the employer to release employment-related information to the insurance company. Sections of the form focus on the applicant's income before the accident, outlining gross income, tips, commissions, and other monetary compensation, which helps in calculating potential benefits. Moreover, it inquires about any possible absences from work due to the accident and assesses eligibility for other types of compensation such as income continuation or medical benefits. Employers are also required to verify this information and provide a declaration concerning the accuracy of the data provided, underscoring the legal responsibility to offer truthful and correct information under the penalties of the Insurance Act and the Criminal Code. The completion and submission of this form are pivotal steps in facilitating the timely and appropriate settlement of claims.

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Form NameOcf 2 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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Return this form to:

Employer's Confirmation

Form (OCF-2)

Use this form for accidents that occur on or after November 1,1996.

Claim Number:

Policy Number:

Date of Accident:

(YYYYMMDD)

If your insurance company asks you to complete this form, fill in parts 1 through 3 and give the form to your employer or former employer(s) to complete the rest. Please have each employer you listed on your Application for Accident Benefits form fill out a separate form. Extra forms are available from your insurance company. Your employer(s) will return the form(s) directly to the insurance company.

Please print clearly.

Part 1

Applicant Information

Last Name

 

 

 

 

 

 

First Name and Initial

 

 

 

 

 

 

 

 

 

Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

Province

 

 

 

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth

 

year

month

day

Home

 

Area Code

Work

 

 

Area Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

Telephone

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Insurance Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

Province

 

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Policyholder

Policy Number

Part 2 Authorization

I authorize my employer to disclose to my insurance company or its authorized representative, any relevant information about my employment, including copies of relevant documents directly relating to my application for income replacement benefits and details of any collateral sources of income or benefits.

Name of Applicant or Substitute Decision Maker (please print)

Signature of Applicant or Substitute Decision Maker

Date (YYYYMMDD)

Part 3

 

 

 

Employed

What Salary

To my employer or former employer:

I was involved in an automobile accident on:

Information

 

 

 

 

 

year

month day

 

is Needed

 

 

 

 

 

To process my application, my insurance company needs information about my salary for the following period before the date of the accident. (If you check both, the insurance company will determine which period provides the highest benefit.)

4 weeks

52 weeks

Self-Employed

If you are or were self-employed at any time during the four weeks before the accident, please consider yourself the employer for the purpose of completing this form.

I was self-employed four weeks before the accident and I designate the following time period to be used to calculate my

income (check one

and proceed to part 4).

 

 

 

52 weeks

 

 

year

month

day

Last complete

From

 

 

 

 

 

 

 

fiscal year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

year

month

day

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The rest of this form must be completed by your employer or former employer.

Part 4

Applicant's

What was the applicant's actual gross income for the period before the accident date checked

If the employee worked only part of the period, list the gross income received from you during the period.

Income

Salary

Tips, Commissions

Other Monetary Compensation

Total

 

Gross Weekly Income Last 4 Weeks

 

Gross Income for Last

Self-Employed: Gross

 

 

Before Accident

 

52 Weeks Before Accident

Income

 

 

 

 

 

 

 

 

 

Week 1

 

Week 2

Week 3

 

Week 4

No. of Weeks

Gross

 

 

 

 

 

 

 

Worked

Income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCF-2 (11/04)

Page 1 of 2

Part 4

Applicant's Income

(cont'd)

additional sheets attached

Part 5

Other

Benefits

Was the applicant absent from work for any time during the period checked ( ) in Part 3?

Yes (Give details below)

No

 

 

 

 

Are there any other types of compensation available from the employer?

Yes (Give details below)

No

 

 

 

 

To your knowledge, is the applicant eligible to receive the following benefits?

Income Continuation Benefit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Company

Policy No.

 

 

 

 

 

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(short-term or long-term disability plan)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplementary Medical,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Company

Policy No.

 

 

 

 

 

Rehabilitation or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attendant Care Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick Leave

No

 

 

 

 

 

 

Yes

 

 

 

 

 

 

Did applicant use sick credits

No

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

following the auto accident?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the applicant a member of a union?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does or did the applicant contribute to the Canada Pension Plan or a similar plan?

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was a claim filed with the Workplace Safety and Insurance Board as a result of this accident?

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Employment

year

month

day

 

 

year month day

Latest Job Title

 

 

 

 

Part 6

 

 

 

 

From:

 

 

 

To:

 

 

 

 

 

 

 

 

Employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Date Worked:

year

month

day

 

 

Date of Return to Work (if applicable)

year

month

day

Details

 

 

 

 

 

 

 

 

 

 

 

 

 

additional

 

 

 

 

 

 

 

 

 

 

 

 

 

Brief Job Description

 

 

 

 

 

 

 

 

 

 

 

 

sheets

 

 

 

 

 

 

 

 

 

 

 

 

 

attached

Essential Tasks of Job (Attach physical demand analysis if available):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 7

Employer Information

Type of Employment

Full-Time

Part-Time

 

Casual

 

Seasonal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Company Name

 

 

 

Contact Person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

Tax Reg. # or Business Identification Number (BIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

Province

 

 

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

Area Code

 

 

 

FAX

 

Area Code

 

 

 

 

 

 

 

Number

 

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 8

Signature

I certify that the information provided is true and correct. I understand that it is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance. I further understand that it is an offence under the federal Criminal Code for anyone, by deceit, falsehood, or other dishonest act, to defraud or attempt to defraud an insurance company.

Signature of Employer:

 

 

 

 

 

year

month

day

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name: (Please print)

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCF-2 (11/04)

Page 2 of 2

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1. Start completing your form employer confirmation sample with a group of major blank fields. Get all of the required information and make certain there's nothing left out!

The best way to prepare form employer confirmation make part 1

2. Once your current task is complete, take the next step – fill out all of these fields - City, Province, Postal Code, Name of Policyholder, Policy Number, Part Authorization of any, I authorize my employer to, Name of Applicant or Substitute, Signature of Applicant or, Date YYYYMMDD, Part What Salary Information is, To my employer or former employer, Employed, year, and month with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

How to prepare form employer confirmation make stage 2

3. This next step is pretty simple, Week, Week, Week, Week, No of Weeks, Worked, Gross Income, Salary, Tips Commissions Other Monetary, and OCF Page of - these fields will need to be filled out here.

Week, Tips Commissions Other Monetary, and Week inside form employer confirmation make

4. This next section requires some additional information. Ensure you complete all the necessary fields - Part Applicants Income contd, Part Other Benefits, Was the applicant absent from work, Yes Give details below, Are there any other types of, Yes Give details below, To your knowledge is the applicant, Income Continuation Benefit, Supplementary Medical, Sick Leave, Yes, Yes, Yes, Insurance Company, and Policy No - to proceed further in your process!

form employer confirmation make conclusion process described (portion 4)

Be really mindful when filling out Sick Leave and Policy No, as this is where most users make errors.

5. And finally, the following last subsection is what you'll have to wrap up prior to using the form. The blank fields you're looking at are the next: Part Employment Details, additional sheets attached, Part Employer Information, Date of Employment, year, month, day, year month day, Latest Job Title, From, Last Date Worked, year, month, day, and Date of Return to Work if.

Step number 5 for completing form employer confirmation make

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