Name First Last Email* Phone*Type of Incident*Type of incident...Personal InjuryProduct LiabilityProperty DamageWrongful DeathCivil Matters & DisputesInjury BenefitsPlease SpecifyPlease specify...Animal AttacksMotor Vehicle & TrafficNegligencePersonal Injury AbusePremises Liability/Fall Down CasesMedical IssuesPlease SpecifyPlease SpecifyLandlord-TenantAppealsStatue of Limitations in OntarioDate of Incident MM slash DD slash YYYY Motor Vehicle & Traffic AccidentsPlease answer the questions below to the best of your ability.Where did the accident occur? Were the Police involved? Yes No Were charges laid? Yes No Slip & Fall AccidentsPlease answer the questions below to the best of your ability.Have you reported your accident?Note: Accidents on Municipal properties must be reported within 7 days. Yes No Are you aware of any independent witnesses? Yes No Did you leave the accident in an ambulance? Yes No Did you visit the hospital, clinic or family doctor after the accident? Yes No Did you receive any injuries? Yes No Please specify:Did your doctor perform any tests? Yes No What were the results?Did you require and therapy sessions or follow up appointments because of your injuries? Yes No Were you working at the time of the accident? Yes No Did you miss time from work as a result of the accident? Yes No How many working days did you miss?Have you completed the AB Application form and submitted it to your Insurance Company? Yes No Do you have photos of the fall location and/or your injuries? Yes No File Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 256 MB. Additional InformationPlease include any relevant information that was not collected in the questions above.