A physician uses this application to show that an Ontario car accident caused a catastrophic impairment, such as paraplegia, a qualifying traumatic brain injury or 55% whole person impairment. A catastrophic designation lets the person request extended medical, rehabilitation and attendant care benefits, and the insurer must respond within 10 business days of receiving the application.
The applicant or a substitute decision maker completes and signs Part 1. A physician completes Parts 2 to 5, or a neuropsychologist when the impairment is a brain impairment only, and other regulated health professionals may assist with the assessment.
The applicant or substitute decision maker enters contact details and ticks the applicant's status: a child accepted as an in-patient at a public hospital named in a Guideline or at a paediatric neurological rehabilitation program, currently in a hospital, rehabilitation centre, nursing home or chronic care facility, a first application, or a reapplication with the reason attached. They sign to authorize you to share the information reasonably required to decide whether the impairment is catastrophic.
Enter your name, College registration number, facility and AISI facility number if applicable, and contact details. The SABS allows only a physician to conduct the catastrophic impairment assessment, assisted by other regulated health professionals as reasonably required, or a neuropsychologist when the impairment is a traumatic brain impairment only. The insurer's 10-business-day clock runs from receipt of an application prepared and signed by the person who conducted the assessment.
Under Knowledge of Applicant, tick the option that fits: currently in your care (give the date most recently seen and the number of years in your care), seen to prepare this application, previously in your care but no longer actively followed, or file reviewed without seeing the applicant (give the date of the most relevant material). Also record how many times you saw the person to evaluate impairment.
Only for applicants under 18 at the time of the accident. Confirm one of two traumatic brain injury criteria: in-patient admission to a public hospital named in a Guideline with positive CT, MRI or other recognized brain imaging showing intracranial pathology, or in-patient admission to a neurological rehabilitation program at a paediatric rehabilitation facility that belongs to the Ontario Association of Children's Rehabilitation Services. Complete Section A or Section B, never both.
For everyone else, describe the impairments using the applicable definition as a guide and, if relevant, the whole person impairment rating from the AMA Guides, 4th edition. Tick every criterion that applies: paraplegia or tetraplegia, severe impairment of walking or arm use or amputation, loss of vision in both eyes, traumatic brain injury (adult or child), 55% or more whole person physical impairment, mental or behavioural impairment combined with physical impairment reaching 55%, or a Class 4 or 5 mental or behavioural impairment.
Items 6 and 7, and the analogous test for children, apply only if two years have passed since the accident or a physician's assessment at least three months after it finds 55% or more whole person impairment that is unlikely to improve below 55%. Item 8 applies after two years, or if a physician states in writing that the impairment is unlikely to improve to less than Class 4 in three or more areas. Tick the box when you attach the description of impairments.
Sign to confirm that the applicant suffered a catastrophic impairment as described in the relevant definition attached, and that the information is true and correct. The declaration notes that knowingly making a false or misleading statement to an insurer is an offence under the Insurance Act. The note below the signature says the fee is not a Ministry of Health benefit: bill the fee and any examinations needed to the insurance company.
The appendix summarizes section 3.1 of the SABS, which prevails if they differ. It names the measures: ASIA Impairment Scale grade and Spinal Cord Independence Measure item 12 for spinal cord and leg impairments, visual acuity of 20/200 (6/60) or less or a field of 20 degrees or less, the Extended Glasgow Outcome Scale at one month, six months or one year for adults, and the King's Outcome Scale for Childhood Head Injury for children.
Download the current version from the source each time; forms change without notice.
Application for Determination of Catastrophic Impairment
Demande de détermination pour une déficience invalidante
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Sources for this guide
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A physician, who may be assisted by other regulated health professionals as reasonably required. When the impairment is a brain impairment only, a neuropsychologist may complete it instead. The applicant or a substitute decision maker completes and signs Part 1, and the physician completes Parts 2 to 5, including the Part 4 criteria and the certification in Part 5.
Two years after the accident, or earlier if a physician's assessment done three months or more after the accident finds 55% or more whole person impairment that is unlikely to improve below 55%. For the Class 4 or 5 mental or behavioural criterion, it is two years, or earlier if a physician states in writing that the impairment is unlikely to improve below Class 4 in three or more areas.
Ten business days from receiving an application prepared and signed by the person who did the assessment. The insurer must say the impairment is catastrophic, or that it is not, with medical and other reasons and whether it requires its own examination. Within 10 business days of that examination report, it must send a copy to the applicant and to you and give its decision.
The auto insurer. The form notes that the fee is not a Ministry of Health benefit, so the fee and the cost of any examinations needed are billed to the insurance company. The SABS requires insurers to pay reasonable fees for preparing the application, including any assessment, within FSRA's guideline maximums and the SABS cap on any one assessment and its reports.