Insurance – Forms

To submit your forms

Follow the directions on the form for submission instructions. If you have any questions, contact the Alberta Superintendent of Insurance.

AB 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).
• See Guideline 03-2024: Diagnostic and Treatment Protocols Regulation (DPTR) Interpretative Guideline – April 10, 2024
  • This guideline supersedes the previous Diagnostic and Treatment Protocols Regulation Interpretative Guide (Archived) – August 23, 2018
• 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.

Current prescribed fees and disbursements for completion of Accident Benefit Claims forms under the DTPR

• Notice 09-2018: Fees and Disbursements for Accident Benefit Claims – September 18, 2018
• Bulletin 06-2015: Notice of Fees and Disbursements for Chiropractic Services – effective February 1, 2016
• Bulletin 04-2013: Notice of Fees and Disbursements for Physical Therapy Services – effective June 1, 2013
• Bulletin 01-2005: Notice of Fees and Disbursements for Services related to Diagnostic and Treatment protocols and Minor Injury Regulation – effective January 17, 2005

How to submit forms

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 (that is, size and colour of answer boxes, etc.) may be altered for compatibility with practitioners’ software, but any changes to the content of the forms (that is, 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, email [email protected]. For all other inquiries, 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.

• AB-1: Notice of Loss and Proof of Claim Form to be completed by claimant – 2017
• AB-1A: Claim for Disability Benefits Form to be completed by physician – 2017
• AB-2: Treatment Plan Form to be completed by primary health care practitioner – 2017
• AB-3: Progress Report Form to be completed by primary health care practitioner at request of insurer – 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 – 2017
• AB-5: Referral to Injury Management Consultant Form to be completed by the primary health care practitioner who is requesting the consult – 2017

Minor injury – annual increase in amount for non-pecuniary damages

• Bulletin 09-2022: Minor Injury Regulation – Annual Increase in Amount for Non-Pecuniary Damages – November 25, 2022. Effective January 1, 2023, replaces Bulletin 05-2021.

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) – 2017
  • See related Superintendent of Insurance Bulletin 01-2017
• MI-2: Application to the Superintendent of Insurance to select a Certified Examiner to be completed online by the applicant (either the claimant or the insurer) – June 2019
  • See related Superintendent of Insurance Notice 03-2019
  • Please note: For selection of a Dentist as a Certified Examiner, please contact the office of the Superintendent of Insurance at [email protected].
• MI-3: Certified Examiner Prescribed Form for Providing an Opinion to be completed by the Certified Examiner – 2017
  • See related Superintendent of Insurance Bulletin 01-2017

Minor injury – Certified Examiner Register

• Certified Examiner Register – 2022

Diagnostic and Treatment Protocols Regulation – Injury Management Consultant Registers

• Physicians Register – 2024
• Chiropractors Register – 2024
• Physical Therapists Register – 2024

Forms and more

Automobile insurance policies, certificates, application forms

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 – 2018

This form replaced the former form effective September 1, 2018. See related Notice 05-2018: Updated Automobile Insurance Motor Vehicle Inspection Report – 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

The following form is used for insurance claim disputes only, under Section 519 of the Insurance Act. For complete information on the Dispute Resolution Process, see insurance consumer complaints.

• FSRP10948, Application to the Superintendent of Insurance to Select an Umpire (General Insurance and Hail Crop Insurance) – 2016

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Contact

If you have trouble opening fillable PDF forms, see the Forms page for instructions.

Connect with the Office of the Alberta Superintendent of Insurance:

Hours: 8:15 am to 4:30 pm (open Monday to Friday, closed statutory holidays)
Phone: 780-643-2237
Toll free: 310-0000 before the phone number (in Alberta)
Fax: 780-420-0752
Email: [email protected]

Address:
Alberta Superintendent of Insurance
Alberta Treasury Board and Finance
Financial Sector Regulation and Policy
402 Terrace Building
9515 107 Street
Edmonton, Alberta  T5K 2C3