B.I.S. Assignment Form


Please fill in the form below in full, then click "Submit" to submit your request.


* Denotes required fields




Contact Information      
Date of Request: Requester:*
Company:* Office Location:
Telephone: Fax:
Email:* Principle (if applicable):
Claim No: Policy No:
Claimant/Subject Information      
Surname: Given Name (1):
Given Name (2) : Date Of Birth:
Primary Address: Secondary Address:
Residential Telephone: Celluar Telephone:
Drivers Licence No: Claimant/Subject Description:
Marital Status: Spouse's Name:
Children / Ages:  
Vehicle Information      
Accident Vehicle (year/make/model): Licence Plate:
Write Off?

Other Vehicles
    License Plate of other vehicles:
Employment Info      
Employer: Employer's Address:
Employer's Telephone: Occupation:
Comments / Remarks:  
Claim Information      
Date of Loss : Type of Claim:
If it is an Accident Benefit Claim, please check the following:
IRB Claim Caregiving Claim House Keeper Claim  
Stated Injuries :
Nature of Claim :
Associated Persons & Locations      
Lawyer: Address:
Doctor: Address:
Physio/Rehab Address:
Chiropractor: Address:
Other: Address:
Type of Investigation      
Select Type of Investigation :
Specific days or dates:




Budget: Plus HST?




^ Back to Top