Disability claim - Form - Step 4 of 10
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4 Injury Information
Occupation
Original date of hire
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Is your injury/illness work related?
Yes
No
Was the reason you stopped working due to:
Illness
Injury away from work
Motor Vehicle accident
Please provide a copy of the police report.
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If you have suffered an injury, please describe how, when and where the injury occured.
Is there any legal action?
Yes
No
Lawyer's name
Phone number
Lawyer's address (number, street, suite)
City
Province
Select a Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
Postal code
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