ICBC Consent to Sharing Information

Please correct the errors described below.

I hereby authorize

to submit to the Insurance Corporation of British Columbia (ICBC) the Report identified below (“Report”), which contains medical information related to a motor vehicle accident dated

I understand that the information contained in the Report can be used by ICBC in connection with my insurance claim.

A photocopy or electronic version of this authorization is as valid as the original.

I have read and understood the contents of this document and I hereby consent to the sharing of the Report with ICBC, and the use of my medical information contained therein as indicated above.

Your information will be encrypted.