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First name:

Last name:

Daytime phone number:

Alternate phone number:

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House/Apartment/P.O. Box Number:

Street name/Route:

Street type:

Suite/room number:

City/Town/Municipality:

Province:

Postal code/zip code:

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Date of MPIC Internal Review Decision:

MPIC Internal Review Decision Number:

Date of accident:

I do not agree with MPIC's decision for the following reason(s):

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Automobile Injury Compensation Appeal Commission (AICAC)

301-428 Portage Avenue

Winnipeg, Manitoba R3C0E2

Contact Information

Residential Address

Mailing Address

Same as residential Yes No

Alternate Contact Information

Please provide an alternate contact, if for some reason the Commission cannot reach you (optional)

First name:

Last name:

Daytime phone number:

Alternate phone number:

Email address:

YOU ARE REQUIRED TO NOTIFY THE COMMISSION IN WRITING IF YOUR CONTACT INFORMATION OR ADDRESS CHANGES.

Appeal Information

Additional Appeal(s)

Appeal Information

Representation

Will someone else be helping you? Yes No (If you obtain a representative to help with your appeal, you may advise the Commission at anytime.)

Please indicate who that will be: Claimant Adviser Office (?) Lawyer Family Member Advocate Executor/Administrator of estate

If you will be represented by a Claimant Adviser, Lawyer, or other representitive, the Commission will communicate directly with them.

Mediation

Mediation is an informal and confidential process in which a neutral third party (the Mediator) helps the parties to resolve issues in dispute. By helping to clarify issues, the Mediator will work with both parties to find solutions that are agreeable to both parties.

Mediation is offered by the Automobile Injury Mediation (AIM) office. For more information on the services provided by AIM, click here.

In addition to proceeding with this appeal at the Commission, I request the option of Mediation. I consent to the Commission providing documents related to this appeal to the Automobile Injury Mediation Office for the purpose of mediation of this appeal. I understand that by agreeing to mediation, I am not giving up my right to appeal.

I request the option of Mediation Yes No

Supporting Documents

If available, please include a copy of your MPIC Internal Review Decision. Click here to open a separate email window that will allow you to send AICAC the attachment in a .pdf or .jpeg file format.

Upon review of the information provided, if additional documents are required from you, AICAC staff will contact you using the information provided in the Contact Information section of this form.

Declaration of Applicant

By checking this box, I declare that:

All the information given in this Notice of Appeal is true in every respect
I will notify the Automobile Injury Compensation Appeal Commission if there are any changes that may be relevant to my appeal

This information is collected under the authority of the Manitoba Public Insurance Corporation Act. This information is used for the purposes of conducting the appeal hearing and arriving at a decision.

If you need assistance completing this form or have questions about the information being collected, please call AICAC at (204) 945-4155 or toll free at 1 (855) 548-7443.

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