Auto Insurance Standard InvoiceAuto Insurance Standard InvoiceAuto Insurance Standard Invoice
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Auto Insurance Standard Invoice
Use this form for accidents that occur on or after November 1, 1996

**Claim Number:
**Policy Number:
Date of Accident:

To be used for medical and rehabilitation goods and services that are payable
by an automobile insurer. The User Manual for completion of the form and its
versions may be found at

Attach Version C - pages 2 and 3 for Minor Injury Guideline for accidents that occurred
on or after September 1, 2010 or Pre-Approved Framework (PAF) treatments for
accidents that occurred prior to September 1, 2010.

Confidentiality: Collection, use and disclosure of this information are subject to
all applicable privacy legislation.

Attach Version A - page 2 where there is a previously approved treatment or
assessment plan.

As indicated on the form, all attachments are sent directly to the insurer.

Version B - pages 2 and 3 must be used for all other goods and services and may be
used for previously approved treatmen