Last Name

Email

Home Phone
1-––

Address

Unit Number

City

Province

Country

Postal Code

Home Phone
1-––

Daytime Phone
1-––

Best Email

Date & Time of Incident
Year: –19961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Month: –JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day: –12345678910111213141516171819202122232425262728293031

Hour: –123456789101112 Minute: –00153045 –AMPM

Location of Incident

In as much detail as possible please describe the accident and what happened

In as much detail as possible please describe your injuries

Did the accident happen at work?
Yes No

If employment related, do you have access to WSIB coverage?
Yes No

Were you off work due to injury?
Yes No

If so, how long were you off work?

Do you have group insurance at work?
Yes No

In as much detail as possible please describe your treatment to date and by whom have you been treated

Were you able to return to normal activities after the accident?
Yes No

If this was a Motor Vehicle Accident, have you completed and submitted an Application for Accident Benefits (OCF-1) with your own insurance company?
Yes No

If this was a slip and fall accident did this happen on city property?
Yes No

Do you have personal insurance?
Yes No

If yes, who is your insurer?

Do you speak fluent English? If NO please advise language and dialect.
–YESNO

Other notes

How did you hear about Morell Kelly?

Bill Boards/Benches Radio Google/Internet Yellowpages Online Goldbook Online Sponsorship Yellowpages Phone Book Facebook Other Other:

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NOTE: If you have any pictures of the accident scene, witness statements and/or contact information for any witnesses please also ensure that you bring this with you to your initial consultation meeting with us.

If there is anything that we can assist you with, please do not hesitate to contact us. Our team is prepared to provide you with the personalized, one-on-one service that you deserve.

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