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Accident Benefit Claims and Minor Injuries
Clarification regarding fees and disbursements for completion of Accident Benefit Claims forms
- The fees for physical therapy services, chiropractic services and Accident Benefit (AB) claim forms completion prescribed in Superintendent of Insurance Bulletins only apply to claims made under the Diagnostic and Treatment Protocols Regulation (DTPR).
- Amounts established by the Health Information Regulation pursuant to the Health Information Act for the provision of full or partial copies of health records apply to all claims made under the DTPR.
- The prescribed AB claim forms are to be used for claims made under both the DTPR and the Automobile Accident Insurance Benefits Regulation (AAIBR).
- Completion of the AB-2, AB-3 and AB-4 claim forms under the AAIBR is at the request of the insurer. Expenses for completion of AB claim forms and services under the AAIBR are not prescribed, and must be reasonable.
- For more information, see Superintendent of Insurance Interpretation Bulletin 09-2018 (PDF, 274 KB).
Current prescribed fees and disbursements for completion of Accident Benefit Claims forms under the DTPR
- Bulletin 06-2015: Notice of Fees and Disbursements for Chiropractic Services (PDF, 104 KB) (effective February 1, 2016)
- Bulletin 04-2013: Notice of Fees and Disbursements for Physical Therapy Services (PDF, 44 KB) (effective June 1, 2013)
- Bulletin 01-2005: Notice of Fees and Disbursements for Services related to Diagnostic and Treatment protocols and Minor Injury Regulation (PDF, 10 KB) (effective January 17, 2005)
How to submit forms
- Please complete the form and follow the directions on the form for submission instructions.
Notice from the Superintendent of Insurance regarding recreating these forms for compatibility with health care practitioner software
- Users may recreate these approved forms in order to ensure compatibility with their own software system.
- Section 803 of the Insurance Act (the Act) provides the Superintendent of Insurance (Superintendent) the power to establish relevant forms. The position of the Superintendent is that the format of the Accident Benefit (AB) and Minor Injury (MI) forms (i.e. size and colour of answer boxes, etc.) may be altered for compatibility with practitioners’ software, but any changes to the content of the forms (i.e. word order, phrasing, question order, etc.) or the addition of corporate logos, is not allowed.
- Moreover, making content changes constitutes a breach of sections 507 and 551 of the Act and is an offence under section 780.
- Users are responsible for updating their systems to remain current with any approved changes to forms in the future.
- If you wish to be notified of future changes, subscribe to receive email updates. For technical support, please email [email protected]. For all other inquiries, please email [email protected].
Accident Benefit Claim - Prescribed Forms
The following prescribed Accident Benefit Claim forms were updated in April 2017. For a description of the changes, see Superintendent of Insurance Bulletin 01-2017 (PDF, 75 KB).
- AB-1: Notice of Loss and Proof of Claim Form to be completed by claimant (PDF, 315 KB) (April 11, 2017)
- AB-1A: Claim for Disability Benefits Form to be completed by physician (PDF, 228 KB) (April 11, 2017)
- AB-2: Treatment Plan Form to be completed by primary health care practitioner (PDF, 221 KB) (April 11, 2017)
- AB-3: Progress Report Form to be completed by primary health care practitioner at request of insurer (PDF, 223 KB) (April 11, 2017)
- AB-4: Concluding Report Form to be completed by the primary health care practitioner who provided the treatment and completed Form AB-2, or who competed the majority of treatment visits (PDF, 224 KB) (April 11, 2017)
- AB-5: Referral to Injury Management Consultant Form to be completed by the primary health care practitioner who is requesting the consult (PDF, 220 KB) (April 11, 2017)
Minor Injury - Amounts effective January 1, 2019 and January 1, 2020
- Bulletin 12-2019: Minor Injury Regulation - Annual Increase in Amount for Non-Pecuniary Damages (PDF, 372 KB) (November 25, 2019) (effective January 1, 2020)
- Bulletin 10-2018: Minor Injury Regulation - Annual Increase in Amount for Non-Pecuniary Damages (PDF, 345 KB) (December 14, 2018) (effective Janury 1, 2019)
Minor Injury - Prescribed Forms
- MI-1: Request for an Assessment by a Certified Examiner Notice Form to be completed by the applicant (either the claimant or the insurer) (PDF, 304 KB) (April 11, 2017)
- See related Superintendent of Insurance Bulletin 01-2017 (PDF, 75 KB)
- MI-2: Online form to be used effective June 30, 2019:
Application to the Superintendent of Insurance to select a Certified Examiner to be completed by the applicant (either the claimant or the insurer)
- See related Superintendent of Insurance Notice 03-2019 (PDF, 287 KB)
- MI-3: Certified Examiner Prescribed Form for Providing an Opinion to be completed by the Certified Examiner (PDF, 222 KB) (April 11, 2017)
- See related Superintendent of Insurance Bulletin 01-2017 (PDF, 75 KB)
Minor Injury - Certified Examiner Register
- Certified Examiner Register (May 22, 2020)
Diagnostic and Treatment Protocols Regulation - Injury Management Consultant Registers
- Physicians Register (August 30, 2019)
- Chiropractors Register (February 13, 2019)
- Physical Therapists Register (May 8, 2020)
Automobile Insurance Policies, Certificates, Application Forms
Please see the automobile insurance page for the following documents:
- Current and Previous Standard Automobile Insurance Policies, Certificate and Application Forms
- Automobile Insurance Endorsements
Motor Vehicle Inspection Report Form
This report is for insurance underwriting purposes only, and required only if the vehicle is 12 years or older. A Certified Automotive Technician must complete the report.
- FSRP11463, Automobile Insurance Motor Vehicle Inspection Report (PDF, 154 KB) (April 18, 2018)
This form replaced the former form effective September 1, 2018. See related Notice 05-2018: Updated Automobile Insurance Motor Vehicle Inspection Report (PDF, 353 KB) (May 29, 2018).
Forms for Insurers, Reciprocal Insurance Exchanges and Exempt Entities
See Information for insurers for forms, Filing Requirements and the Insurance Regulatory Information System (IRIS).
Insurance Dispute Resolution Process Form
- FSRP10948, Application to the Superintendent of Insurance to Select an Umpire (General Insurance and Hail Crop Insurance) (PDF, 258 KB) (September 28, 2016)
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To connect with the Office of the Alberta Superintendent of Insurance
Alberta Superintendent of Insurance
Alberta Treasury Board and Finance
Financial Sector Regulation and Policy
402 Terrace Building
9515 107 Street
Edmonton, Alberta T5K 2C3