Ontario auto insurers rely on this certificate to decide income replacement, non-earner, caregiver, housekeeping and lost educational expense claims after a car accident. The applicant fills in Parts 1 to 4, then a health practitioner records the accident-related injuries with ICD-10-CA codes, answers the disability tests and estimates how long the disability will last. For most of these benefits, the insurer then has 10 business days to pay, refuse with reasons or ask for more information.
The applicant completes Parts 1 to 4 and signs Part 4 once the practitioner has explained the accident-related injury. A health practitioner of the applicant's choice, such as a physician, chiropractor, physiotherapist or psychologist, completes Parts 5 to 10 from their most recent examination.
The applicant enters personal details, whether they were working at the time of the accident, whether they worked 26 of the previous 52 weeks or received Employment Insurance, and their caregiver and education status. They name the insurer and policy holder and briefly describe the accident and injuries. In Part 4 they sign after you explain the injury, authorizing you to share relevant health information with the insurer and, if necessary, to contact their employer about essential tasks and modified hours or duties.
List each injury and sequela that is a direct result of the accident, most significant first, with its ICD-10-CA code. The form points to the HCAI user manual at hcaiinfo.ca for coding. Keep pre-existing or unrelated conditions out of this part, because Part 8 is where they belong. The SABS defines a disability certificate as one that states the cause and nature of the impairment, and this list is where the insurer reads it.
Give the dates symptoms first appeared, of the first post-accident examination and of your most recent examination. Then answer each test: a substantial inability to perform the essential tasks of employment within 104 weeks of the accident, whether modified hours or duties are possible, a complete inability to carry on a normal life, a substantial inability to provide caregiving, an inability to continue an education program, and a substantial inability to perform housekeeping and home maintenance. Explain any Yes where the form asks.
If you answered Yes to any disability test, tick the anticipated duration: 1 to 4, 5 to 8, 9 to 12 or more than 12 weeks. Choosing more than 12 weeks requires a written explanation of why the task or activity limitations are likely to persist beyond 12 weeks. The SABS definition of a disability certificate includes an estimate of the duration of the disability, so complete this whenever a test is met.
Answer two questions. First, have there been examinations, investigations or consultations not previously reported by you? If yes, specify the findings and results. Second, are further examinations, investigations or consultations contemplated or required? If yes, specify them. On a repeat certificate, this part tells the insurer what is new since your last report and what is still pending.
State whether, before the accident, the applicant had a disease, condition or injury that affected their ability to perform the Part 6 activities (Yes, No or Unknown), and whether they receive disability benefits for it. If you treated similar conditions before the accident, describe the date of onset, later interventions and status at the time of the accident. Then report any condition unrelated to the accident that has developed since and could affect the disability.
Part 9 has two lists. The first covers medications, with dosage and frequency, that the applicant currently takes for injuries related to the accident. The second covers medications taken because of the prior or concurrent conditions identified in Part 8. For each list, tick whether you prescribed them. Use the same split between accident-related and other conditions that you used in Parts 5 and 8.
Enter your name, College registration number, facility and AISI facility number if applicable, contact details and profession. The listed professions are chiropractor, dentist, nurse practitioner, occupational therapist, optometrist, physician, physiotherapist, psychologist and speech-language pathologist. Signing certifies the information is true and correct, and the declaration notes that a knowingly false or misleading statement to an insurer is an offence under the Insurance Act. The note at the bottom says to bill the completion fee to the insurer directly.
Download the current version from the source each time; forms change without notice.
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 health practitioner of the applicant's choice, as the SABS defines it: a physician, or a chiropractor, dentist, nurse practitioner, occupational therapist, optometrist, physiotherapist, psychologist or speech-language pathologist when the impairment is one they are authorized by law to treat. The applicant fills in Parts 1 to 4, and the practitioner completes Parts 5 to 10 and signs Part 10.
Yes. Income replacement, non-earner, caregiver, housekeeping and lost educational expense benefits became optional for policies entered into or renewed on or after July 1, 2026, and now cover only the named insured, their spouse and dependants, and listed drivers. When a claim includes one of these benefits, the SABS still requires a completed disability certificate, and FSRA updated the OCF-3 for the change.
Within 10 business days of receiving the application and completed certificate, the insurer must pay the benefit, explain the medical and other reasons it believes the person is not entitled, or ask for more information. If it requires an insurer examination, it must send a copy of the report to the applicant and to the practitioner who completed the certificate within 10 days of receiving it.
It is the income replacement test. The SABS pays this benefit when, as a result of and within 104 weeks after the accident, the person suffers a substantial inability to perform the essential tasks of their employment or self-employment. It can also apply to someone not working at the time who worked 26 of the 52 weeks before the accident or was receiving Employment Insurance.