Government of Ontario

Safety, Licensing Appeals and  Standards Tribunals Ontario
Licence Appeal Tribunal

Automobile Accident Benefits Service

15 Grosvenor Street, Ground Floor
Toronto ON M7A 2G6
Telephone: 416-326-1356
1-844-242-0608
TTY: 416-916-0162
1-800-855-0511
Email: LATregistrar@ontario.ca
1-888-444-0240
Website: www.tribunalsontario.ca/lat

Notice of Withdrawal

Important Information

If you do not want to continue with your appeal, you must provide a written notice of withdrawal to the Tribunal and to the other parties to the appeal.
By withdrawing the appeal, the Tribunal file will be closed.

Tribunal file No.

Notice of Withdrawal:

In the matter of Licence Appeal Tribunal file number
Licence Appeal Tribunal file No.

I, the Applicant
Last Name
Appellant Name: First Name
withdraw my appeal before the Tribunal. I understand that, by withdrawing my appeal, my file will be closed.

Copy to Respondent:

I have sent a copy of this Notice of Withdrawal to the Respondent, or their representative,
Name of Respondent or their Representative: Last Name
Name of Respondent or their Representative: First Name

Name of Insurance Company

By the following method:

Facsimile Regular Mail Personal Delivery Courier

at the following facsimile No. / address

Address Notice of Withdrawal was delivered to:

Unit No.
Street No.
Street Name
PO Box
City
Province
Postal Code

or Facsimile Number of Withdrawal was delivered to

Last Name
First Name

Signature

Date (yyyy/mm/dd)

The Licence Appeal Tribunal collects the personal information requested on this form under section 3 of the Licence Appeal Tribunal Act, 1999. This information will be used to determine appeals under this Act. After an appeal is filed, all information may become available to the public. Any questions about this collection may be directed to the Licence Appeal Tribunal at 416-326-1356 or toll-free at 1-844-242-0608.