| Income source |
What it will pay each month |
| 1. Workers’ Compensation |
$__________ |
| 2. CPP/QPP disability benefits |
$__________ |
| 3. Work plans (such as sick pay, or long-term disability pay) |
$__________ |
| 4. Personal insurance on loans (such as a mortgage, car loan, or other personal loans) |
$__________ |
| 5. Personal disability insurance or critical illness insurance |
$__________ |
| 6. Your personal savings |
$__________ |
| 7. Other sources (such as loans or money from renting property you own) |
$__________ |
| Total: |
$__________ |