Virtual Office
SABS New File Referral Form - Part 1
  About You About Us
Company: KPMG LLP KPMG LLP
Address:
233 Speers Road, Suite 12
Oakville, Ontario
L6K 0J5
 
354 Davis Road, Suite 402
Oakville, ON
L6J 2X1
Telephone: 416-233-5577 (416) 233-5577
Fax: 905-845-8040 (905) 845-8040
Email: theodorekang@kpmg.ca  
ICS Courier 85249-1029
Shaded fields are mandatory.
Adjuster
Name: Telephone: Fax:
Insurer:
Claimant
Claimant's Name: Claim Number:
Claimant's Address: Date Of Loss:
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Claimant's City, Prov: Employment Status:
Employed vs Self-Employed
Guidelines
Claimant's Postal Code:
Claimant's Telephone: Occupation:
Questions by profession
Claimant's Fax:
Date Of Birth:
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Insured's Name:
  Policy Number:
Other Information
Optional Benefits Purchased Amount
Motor Vehicle Written Off Amount
IRBs Paid To Date Amount
Stoppage Date Date
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Returned To Work Date
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Replacement Help Hired  
Collateral Benefits Details
Previous Motor Vehicle Accident: Date
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Additional Information/Special Instructions
Disabilities to be considered under the AODA
Is the claimant represented?
Is there an accountant or other contact information for the claimant?
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