Insurance Regulatory Information System
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Application to the Superintendent of Insurance to Select a Certified Examiner (Form MI-2)

Instructions:

The following fields must be entered prior to submitting the form:

1. Claimant Information (Part 1a)

2. Claimant Legal Representative Information (Part 1b) if the claimant is represented

3. Insurance Company Information (Part 2)

4. Insurance Company Contact Information (Part 2a) if the request is being made by the Insurance Company -or-

5. Insurance Company Legal Representative Information (Part 2b) if the request is being made by Insurance Company's Legal Representative.


After Submission:

1. An email acknowledgement of the submission will be sent to the Superintendent of Insurance and the Submitter Email Address. Please print or download the PDF application to retain a copy for your records as the PDF will not be attached to the email.

2. After the selection process is completed, confirmation emails will be sent to the selected Certified Examiner, Claimant, Claimant's Legal Representative, Insurance Company Contact and Insurance Company's Legal Representative.


General Information
Part 1a: Claimant Information
At least One Phone Number is required for Claimant
At least One Phone Number is required for Claimant
At least One Phone Number is required for Claimant
Select or type value for City
Enter Postal Code in Format 'T5T 4J2' for Canada
Part 1b: Claimant Legal Representative Information
If First Name is entered, all other required fields must be entered
If Last Name is entered, all other required fields must be entered
Select or type value for City
Enter Postal Code in Format 'T5T 4J2' for Canada
Part 2: Insurance Company Information
Part 2a: Insurance Company Contact Information
If First Name is entered, all other required fields must be entered
If Last Name is entered, all other required fields must be entered
Select or type value for City
Enter Postal Code in Format 'T5T 4J2' for Canada
Part 2b: Insurance Company Legal Representative Information
If First Name is entered, all other required fields must be entered
If Last Name is entered, all other required fields must be entered
Select or type value for City
Enter Postal Code in Format 'T5T 4J2' for Canada
Part 3: Certified Examiner Declined by Claimant
Part 4: Certified Examiner Declined by Insurance Company
Part 5: Comments & Signature of Party Applying to Select a Certified Examiner
An email acknowledgement of the submission will be sent to the Submitter Email Address
Submit Form
At least One Phone Number is required for Claimant
At least One Phone Number is required for Claimant
At least One Phone Number is required for Claimant
You must check the confirmation box

Privacy Statement:

The personal information that you provide on this form will be used for the purpose of selecting a Certified Examiner and informing relevant parties of the selection. It is collected under the authority of section 8(4) of the Insurance Act, Minor Injury Regulation, and section 33(c) of the Freedom of Information and Protection of Privacy Act (RSA 2000). It is protected by the provisions of the Freedom of Information and Protection of Privacy Act. Copies of the Minor Injury regulation, Insurance Act, prescribed forms and the Certified Examiner Register are available at https://www.alberta.ca/insurance-forms.aspx.

If you have any questions you can contact the Office of the Superintendent of Insurance by phone at 780-643-2237, or by email at TBF.Insurance-CESelection@gov.ab.ca.

This prescribed form is to be used when a claimant and a defendant cannot agree on a Certified Examiner.

Use this prescribed form for motor vehicle accidents that occur on or after January 1, 2008. This form is prescribed in accordance with Section 8(4) of the Minor Injury Regulation and Section 803 of the Insurance Act.

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