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CLAIM FOR COMPENSATION

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					                      Guide       TO THE
                          CLAIM FOR
                        COMPENSATION
                     to compensate for economic loss,
                     to compensate for a diminished
                     quality of life, and to compensate
                     accident-related expenses




 DIA   A
7236A 40 (2010-04)
                                                       Compensation paid by the SAAQ




                                                                         I
                                    COMPENSATION PAID                                                           BY
                                        THE SAAQ




The three objectives of indemnities paid by the SAAQ are as follows:

Objectives                        Indemnities                                     Categories                                                                 Page


                                                                                  Full-time worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
                                                                                  Person with a
                                                                                  temporary job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
                                  Income replacement
                                  indemnity                                       Part-time worker. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
                                                                                  Unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

 A                                                                                Person regularly unable
                                                                                  to work in any capacity . . . . . . . . . . . . . . . . . . . . . . . . 7
To compensate
for economic
loss due to
an accident                       Care allowance             .....................................................................                                 8

                                  Lump-sum indemnity
                                  for the loss of one                             Student age 16 or over . . . . . . . . . . . . . . . . . . . . . . . . . 9
                                  year of schooling or                            Student under age 16 . . . . . . . . . . . . . . . . . . . . . . . . . . 10
                                  one school term


 B
To compensate for the aftereffects of injury, such
as pain, mental suffering and loss of enjoyment of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


 C
To compensate accident-related expenses                          ...............................................................                                 11




                                                                          1
                            Compensation paid by the SAAQ




                                        A
               COMPENSATION           FOR ECONOMIC LOSS

As compensation for economic loss, you may be entitled to receive one or more
of the following indemnities:
     • Income replacement indemnity
     • Care allowance
     • Lump-sum indemnity for the loss of one year of schooling or one school
       term




                                         ◾
                      Income replacement indemnity

This indemnity is paid to a person who loses employment earnings due to an
accident. It corresponds to 90% of net income, which is based on gross annual
income, but not exceeding the maximum provided for by the Automobile
Insurance Act.
Net income is established by subtracting the amounts of federal and provincial
income tax, employment insurance premiums Québec Parental Insurance Plan
(QPIP) premiums, and contributions to the Québec Pension Plan from gross
income.
Loss, by reason of the accident, of employment insurance benefits payable
under the Employment Insurance Act may be the subject compensation and are,
in certain cases, payable in addition to an income replacement indemnity.
For information on amounts payable, consult the Compensation Table.
PLEASE NOTE: No compensation is payable for the first seven days including
the day of the accident.


Job Categories
In order to make decisions on the payment of your indemnity or indemnities,
your compensation officer will have to determine into which of the following
categories you fit according to the Automobile Insurance Act.
    • Full-time worker
    • Person with a temporary job
    • Part-time worker
    • Unemployed person
    • Person regularly unable to work in any capacity




                                         2
                             Compensation paid by the SAAQ




◾   Full-time worker

    If, at the time of the accident, the injured person had a job of at least
    28 hours per week and had had that job for at least a year, the person is a
    full-time worker.
    This person may be entitled to an income replacement indemnity if he/she
    is unable to work in that capacity because of the accident. The indemnity is
    payable until such time as that person is able to resume his/her employ-
    ment.

    Starting from the 3rd year after the accident
    A person who remains unable to work in any capacity will continue to
    receive the income replacement indemnity, except for persons aged 64
    years or over (see page 7, under Person aged 64 years or over).
    If the person is unable to do the job he/she had at the time of the accident
    but becomes able to work in another capacity, the SAAQ may take this into
    account.


             Determining employment three years after the accident
      The SAAQ may determine the type of employment the accident vic-
      tim would be able to have by taking into account training, experience,
      physical and intellectual ability and, where applicable, knowledge or
      skills acquired under a rehabilitation program.
      Once employment has been determined, the accident victim will con-
      tinue to receive the same income replacement indemnity as before,
      for a period of one year. At the end of the year, the indemnity will be
      reduced by an amount equal to the net income of the employment
      determined for that person.
      Employment is also determined for persons with temporary or part-
      time employment or for persons who are unemployed.




                                          3
                             Compensation paid by the SAAQ




◾   Person with a temporary job

    If, at the time of the accident, the injured person had a job of at least 28
    hours per week, and had held it for less than one year, that person is a tem-
    porary worker.
    The person may qualify for an income replacement indemnity if he/she
    becomes unable to work in that capacity because of the accident.
    For the first 180 days after the accident, the amount of the income replace-
    ment indemnity will be based on the job the person had before the accident
    and will be paid for as long as the accident victim is unable to work in that
    capacity.

    Starting from the 181st day after the accident
    In cases where the disability persists, the accident victim may receive an
    income replacement indemnity based on employment he/she would have
    been able to hold.
    The Société takes into account the following to determine employment for
    the accident victim:
       • the person’s physical and intellectual ability
       • his/her training
       • his/her work experience.
    The amount of the indemnity will be established on the basis of the gross
    income corresponding to employment determined for him/her. The indem-
    nity is paid until the accident victim becomes able to do the job determined
    for him/her.

    Starting from the 3rd year after the accident
    A person who remains unable to work in any capacity will continue to
    receive the income replacement indemnity, except for persons aged 64
    years or over (see page 7, Person aged 64 years or over).
    If the person is unable to do the job determined on the 181st day but
    becomes able to work in another capacity, the SAAQ may take this into
    account.
    For more information, see the table on page 3, Determining employment
    three years after the accident.




                                          4
                              Compensation paid by the SAAQ




◾   Part-time worker
    If, at the time of the accident, the person had a job of less than 28 hours per
    week, he/she is a part-time worker. The duration of employment is irrele-
    vant; it may be more or less than one year.
    The person can qualify for an income replacement indemnity if he/she
    becomes unable to work in that capacity because of the accident.
    For the first 180 days after the accident, the amount of the income replace-
    ment indemnity will be based on the part-time job and will be paid for as
    long as the accident victim is unable to work in that capacity.
    If, at the time of the accident, the accident victim was taking care of, with-
    out pay, one or more children under 16 years of age or of a person with a
    disability, he/she may be entitled to an indemnity covering the cost of care
    (see page 8, Care allowance) if he/she becomes unable to take care of the
    person(s).

    Starting from the 181st day after the accident
    In cases where the disability persists, the accident victim may receive an
    income replacement indemnity based on employment he/she would have
    been able to hold.
    The Société takes into account the following to determine employment for
    the accident victim:
       • the person’s physical and intellectual ability
       • his/her training
       • his/her work experience.
    The amount of the indemnity will be established on the basis of the gross
    income corresponding to employment determined for him/her. The indem-
    nity is paid until the accident victim becomes able to do the job determined
    for him/her.
    An accident victim who was also receiving an indemnity for care expenses
    will no longer receive both indemnities as of the 181st day (see page 8, Care
    allowance).

    Starting from the 3rd year after the accident
    A person who remains unable to work in any capacity will continue to
    receive an income replacement indemnity, except for persons aged 64 years
    or over (see page 7, Person aged 64 years or over).
    If the person is unable to do the job determined for him/her but becomes
    able to work in another capacity, the SAAQ may take this into account.
    For further information, see page 3, Determining employment three years
    after the accident.




                                           5
                               Compensation paid by the SAAQ




◾   Unemployed person

    An accident victim is deemed to be unemployed if he/she was able to work
    at the time of the accident but did not have a job. This person is eligible to
    receive an income replacement indemnity for the first 180 days after the
    accident, only in the following cases:
     • Where that person is unable to hold a job he/she would have had during
       that period, had the accident not occurred;
     • Where, because of the accident, that person is deprived of regular
       employment insurance benefits or an employment assistance allowance
       payable under the Employment Insurance Act.
    If, at the time of the accident, the accident victim was taking care of, without
    pay, one or more children under 16 years of age or of a person with a dis-
    ability, he/she is entitled to an indemnity covering the cost of care (see page
    8, Care allowance) if he/she becomes unable to take care of the person(s).

    Starting from the 181st day after the accident
    In cases where the disability persists, the accident victim may receive an
    income replacement indemnity based on employment he/she would have
    been able to hold.
    The Société takes into account the following to determine employment for
    the accident victim:
       • the person’s physical and intellectual ability
       • his/her training
       • his/her work experience.
    Even though the victim was not entitled to an income replacement indemnity
    in the first 180 days, he/she may receive an income replacement indemnity
    based on the job determined for him/her. The indemnity is paid until such
    time as the accident victim becomes able to do the job determined for him/her.

       EXCEPTION: Persons aged 65 years and older without proof of hiring in
       180 days after the accident will not be entitled to an income replacement
       indemnity.

    An accident victim who was also receiving a care allowance will no longer
    receive both indemnities as of the 181st day (see page 8, Care allowance).

    Starting from the 3rd year after the accident
    A person who remains unable to work in any capacity will continue to
    receive an income replacement indemnity, except for persons aged 64 years
    and over (see page 7, Person aged 64 years or over).
    If the person is unable to do the job determined for him/her but becomes
    able to work in another capacity, the SAAQ may take this into account.
    For more information, see page 3, Determining employment three years
    after the accident.


                                            6
                             Compensation paid by the SAAQ




◾   Person regularly unable to work in any capacity

    A victim who, at the time of the accident, was regularly unable to work in
    any capacity, either full- or part-time, for physical or intellectual reasons
    other than those caused by the accident, is not entitled to receive an income
    replacement indemnity.



                         Person aged 64 years or over
      Persons aged 64 years or over at the date of the accident may qualify
      for a full income replacement indemnity for the year after the
      accident.
      However, this indemnity is reduced by:
      • 25 % as of the second year after the date of the accident
      • 50 % as of the third year
      • 75 % as of the fourth year
      Eligibility for this indemnity ends four years after the date of the
      accident.




                                          7
                         Compensation paid by the SAAQ




                                      ◾
                            Care allowance

An indemnity is paid to an accident victim whose major activity was unpaid
work taking care of children under 16 years of age or disabled persons.
To qualify for this indemnity, this person must have been unemployed or
working only part-time when the accident occurred.
The amount payable varies according to the number of children or disabled
persons he/she was caring for.
The indemnity cannot be combined with an income replacement indemnity
based on employment of more that 28 hours per week.
An accident victim who was also receiving an income replacement indem-
nity will no longer receive both indemnities as of the 181st day.
At the time he/she deems appropriate, that person must choose between the
care allowance and the income replacement indemnity. Pending the
claimant’s decision, only the care allowance will be issued.
For information on amounts payable, see the Compensation Table.




                                      ◾
           Lump-sum indemnity for the loss of one year
                of schooling or one school term

This lump-sum indemnity is given to students who fall behind in their
schooling due to an automobile accident:
 • One year of studies at the elementary and secondary level;
 • One school term at the post-secondary level.
This indemnity is paid at the end of the failed term or year of school.




                                      8
                               Compensation paid by the SAAQ




◾   Student aged 16 years or over
    Students 16 years of age and over who are enrolled full time in a secondary
    or post-secondary educational institution and who fall behind in their
    schooling because they are unable to resume studying due to the accident
    are entitled to a lump-sum indemnity.
    The amount of the indemnity corresponds to the level of schooling.
    The indemnity is no longer payable as of the scheduled date for the end of
    studies in progress at the time of the accident.

      EXAMPLE: A student enrolled in a cégep at the time of the accident and
      who is not yet registered at a university will be able to receive the indem-
      nity until the date on which college-level studies are due to end, unless
      he/she becomes able to resume studying in the meantime.

    The accident victim who also has a job or jobs, or would have held one if the
    accident had not occurred, may be entitled to an income replacement
    indemnity.
    For information on amounts payable, see the Compensation Table.

    Income replacement indemnity
    The accident victim may be entitled to an income replacement indemnity if:
    • he/she held or would have held a job had it not been for the accident;
    • he/she is deprived of regular employment insurance benefits under the
      Employment Insurance Act;
    • he/she is deprived of an employment assistance allowance under the
      Employment Insurance Act.

    The indemnity is paid to the accident victim up to the date when the studies
    then underway were expected to end, only:
     • if the job would have been available and the person was incapable of
       working in that capacity;
     • for as long as the person is deprived of regular employment insurance
       benefits because of the accident;
     • for as long as the person is deprived of an employment assistance
       allowance.

    Starting from the scheduled date for the end of studies underway
    at the time of the accident
    • A person who is unable to resume studying due to the accident is no
      longer entitled to the lump-sum indemnity.
    • A person who is unable to resume studying or to work in any capacity
      may receive an income replacement indemnity. The amount is based on
      the average weekly earnings of Québec workers.
    • A person who is able to work but whose capacity to do so is significantly
      reduced because of the accident might also be entitled to an income
      replacement indemnity.


                                            9
                             Compensation paid by the SAAQ




◾   Student under 16 years of age
    Accident victims who fall behind in their schooling due to the accident are
    entitled to a lump-sum indemnity.
    The amount of the indemnity is based on the level of schooling.
    The indemnity ceases to be paid at the end of the school year during which
    the student turns age 16 or becomes able to resume studying.
    A student who has a job or jobs or would have held one if the accident had
    not occurred, may be entitled to an income replacement indemnity.
    For information on amounts payable, see the Compensation Table.

    Income replacement indemnity
    The accident victim may be entitled to an income replacement indemnity if:
    • he/she held or would have held a job had it not been for the accident;
    • he/she is deprived of regular employment insurance benefits under the
      Employment Insurance Act;
    • he/she is deprived of an employment assistance allowance under the
      Employment Insurance Act.

    The indemnity is paid to the accident victim up to the end of the school year
    during which the student turns age 16, for as long as:
    • the job would have been available and the person would have been inca-
      pable of working in that capacity;
    • the person is deprived of regular employment insurance benefits due to
      the accident;
    • the person is deprived of an employment assistance allowance due to the
      accident.

      EXAMPLE: A newspaper carrier who can no longer deliver newspapers
      due to an accident may receive an income replacement indemnity for the
      period for which he or she was hired.


    Starting at age 16
    From the end of the school year during which the student turns 16:
    • An accident victim who is unable to resume studying due to the accident
      is no longer entitled to the lump-sum indemnity.
    • An accident victim who is unable to resume studying or to work in any
      capacity may receive an income replacement indemnity. The amount of the
      indemnity is based on the average weekly earnings of Québec workers.
    • An accident victim who is able to work but whose capacity to do so is sig-
      nificantly reduced because of the accident might also be entitled to an
      income replacement indemnity.




                                         10
                         Compensation paid by the SAAQ




                                     B
             COMPENSATION            FOR AFTEREFFECTS
Bodily injury sustained in an automobile accident and, eventually, any per-
manent aftereffects, such as mental suffering or pain or loss of enjoyment
of life, may be compensated by the SAAQ with a lump-sum indemnity.
• The amount of lump-sum compensation varies according to the severity of
  injuries and their consequences.
• Accident victims are always compensated based on the maximum amount
  in force on the date of the decision.
• A lump-sum payment is generally made once the health condition of the
  accident victim is considered stable.
• Where there is sufficient medical information on a person’s file, an inter-
  im payment may be made before the final assessment of accident-related
  injuries.
For information on amounts payable, see the Compensation Table.




                                     C
    COMPENSATION          OF ACCIDENT-RELATED EXPENSES
For information on expenses covered and reimbursement conditions, see
page 18, Reimbursement of expenses.




                         Disabled parking permit
  From April 1, 2003 the Société de l’assurance automobile du Québec
  refunds the fee for a disabled parking permit paid by someone who
  has applied for one as the result of an automobile accident.
  The Disabled Parking Permit Application form is available in SAAQ
  service centres.
  If you qualify, you will be sent an Accident Victim’s Disabled Parking
  Permit Fee Refund Application form that you must fill out, sign and
  return, to get your refund.




                                     11
                                          II
                        COMPLETING THE
                    CLAIM FOR COMPENSATION
                                       FORM



                             Identity of the accident victim
    1

◾       Driver’s licence number, social insurance number and
        health insurance number
        Indicate your social insurance number, health insurance number and
        Québec driver’s licence number, if you have one. In the case of a minor who
        does not yet have a social insurance number, indicate the health insurance
        number only. If this information is not provided with your claim, the SAAQ
        will have to contact you for it at a later date. This can cause an unnecessary
        delay in processing your claim for compensation.


◾       Present last name if different from name at birth
        Write the last name you are using at present if it is different from the one
        you had at birth. For example, if you are married and you use your hus-
        band’s name, write that last name.

          PLEASE NOTE: All correspondence sent and cheques issued to you by
          the SAAQ will bear your last name at birth.



◾       Civil status at the time of the accident
        You must indicate what your marital status was at the time of the accident.
        Please check only one box, that is, that which corresponds to your situation
        most recent to the date of the accident. For example, if at the time of the
        accident you were divorced and were part of a common-law relationship,
        check the common law arrangement box.




                                           13
                              Completing the Claim for Compensation form




                                            Accident
    3

◾       Date and time of accident
        Indicate the date and time of the accident as specifically as possible.



◾       Licence plate number
        Indicate the licence plate number of the vehicle you were in. If the accident
        occurred while you were a passenger aboard a bus and you do not know
        what the licence plate number was, leave the space blank.



◾       Province, state or country
        If you have written the licence plate number of the vehicle you were in,
        indicate the province, state or country of origin of the licence plate.



◾       Location of accident
        Indicate the municipality in which the accident occurred.
        If you are covered by one of the two situations described below, you may
        file a Claim for Compensation with the SAAQ.
        • A person from outside Québec, who is involved in an automobile accident
           in Québec and who owns, operates or is a passenger of a motor vehicle
           registered in Québec, is entitled to the same compensation as Quebecers.
        • A person from outside Québec, who operates or is a passenger of a motor
           vehicle that is not registered in Québec, or who is a pedestrian or cyclist,
           will be compensated in the event of an accident in the inverse proportion
           to his/her share of liability, unless that person’s province of residence has
           signed an agreement with the Société de l’assurance automobile du
           Québec.




                                                 14
                          Completing the Claim for Compensation form




◾   If outside Québec, indicate province, state or country

    If the accident happened outside Québec, indicate the province, state or
    country.
    A Québec resident injured in an accident that occurred outside Québec is
    entitled to the same compensation as if the accident had occurred in
    Québec. If this is your case, you may file a claim with the Société de l’assu-
    rance automobile du Québec.
    If by reason of the accident you incurred medical expenses outside Québec
    (hospitalization costs, professional fees, etc.), you must follow the steps out-
    lined below:

    • If you have not yet paid the fees
      Send all supporting documents to the SAAQ. Only originals will be
      accepted.

    • If you have already paid the fees
      File a claim with the Régie de l’assurance maladie du Québec to obtain a
      form entitled Application for reimbursement. See the blue pages of the
      telephone directory under “Santé” for the address.
      Your duly completed form must be accompanied by the appropriate sup-
      porting documents. Please note that the Régie requires the originals.
      You will be reimbursed for your expenses by this agency according to the
      provisions of the Hospital Insurance Act and the Health Insurance Act.
      The supporting documents will be automatically transferred by the Régie
      de l’assurance maladie to the SAAQ, which will then reimburse you for
      the proportion of the amount that was not paid by the Régie and for
      which you are eligible under the Automobile Insurance Act.

    Liability
    If you are at fault for the accident and a person from outside Québec decides
    to launch a lawsuit against you, your private third-party liability insurance
    will cover you for this.
    If it is the person from outside Québec who is deemed at fault for the acci-
    dent, you may, where legal recourse is allowed under the legal jurisdiction
    where the accident took place, initiate court proceedings against that per-
    son. However, before doing so, you must notify the SAAQ of this since as it
    has the preferred right of remedy and may decide to exercise it.
    For further information on this topic, ask the compensation officer assigned
    to your case as soon as the SAAQ receives your Claim for Compensation.




                                             15
                               Completing the Claim for Compensation form




◾       Was a vehicle registered outside Québec involved
        in the accident?
        If you know of a vehicle registered outside Québec that was involved in the
        accident, you must report it.



    4
◾       Give a detailed account of facts related to the accident
        You are required to give a full and detailed description of the facts related
        to the accident even if a police report was filed or a joint report of the acci-
        dent was drawn up. Please indicate:
        • your intended destination;
        • the lane or the intersection where the accident took place;
        • the manoeuvre you were preparing to make;
        • how impact occurred;
        • the number of vehicles involved; and
        • any other relevant fact related to the accident.
        You may also enclose a diagram showing how the accident occurred with
        the Claim for Compensation, using a separate sheet if needed. Make sure to
        indicate your claim number or, if unavailable, your health insurance num-
        ber.



    5
◾       Was an accident report drawn up by a police officer?
        • If a police report was filed following an accident in Québec, it will be for-
          warded to the SAAQ by the police force present at the accident. If you
          know the report number, please indicate it.
        • If the accident occurred outside Québec and you already have the report,
          please attach a copy with the Claim for Compensation.
◾       Was a Joint Report of the accident drawn up?
        If no police report was filed but a joint report of the accident was drawn up,
        please enclose a copy.
◾       Did anyone witness the accident?
        If neither of the above-mentioned documents exists, but there were one or
        more eyewitnesses to the accident, please provide the identity of one of the
        witnesses. If need be, that witness could be called upon to corroborate your
        statement.

           NOTE: The witness may be one of the persons involved in the accident.



                                                  16
                              Completing the Claim for Compensation form




    6

◾       Did the accident occur…

        In the context of work
        If the accident took place while at work, do not fill out this form. Your claim
        should be addressed to the Commission de la santé et de la sécurité du tra-
        vail du Québec (CSST) or to the appropriate agency outside Québec respon-
        sible for compensating victims of work-related accidents. This does not
        apply if you were already on leave following an industrial accident when the
        automobile accident occurred.
        A car accident is considered as taking place in the context of work in cases
        where:
        • the accident took place on the employer’s property during business hours;
        • the victim was travelling during business hours paid for by the employer;
        • the person was carrying out orders or running an errand for his/her
          employer;
        • the person was travelling in a vehicle owned by the employer;
        • the person was using a means of transportation provided by the employer;
        • the employer paid for the travel expenses.
        However, if you have already applied for compensation from the CSST and
        were turned down, you may file a Claim for Compensation with the SAAQ,
        including the letter of refusal from the CSST.

        Victims of a criminal act
        If the driver of a motor vehicle intentionally caused bodily injury, you are a
        victim of a criminal act and may decide to seek compensation under the
        Criminal Victims Compensation Act or the Automobile Insurance Act.

        While assisting a person in distress
        If you were involved in an automobile accident while assisting a person in
        distress, you are considered an accident victim engaged in an act of good
        citizenship, and you may therefore seek compensation under the Act to pro-
        mote good citizenship or the Automobile Insurance Act.
        In either case, compensation is paid under only one Act. If you would like to
        know which Act would be more advantageous, you may initially file a claim
        for compensation with both agencies that administer these Acts, i.e. the
        SAAQ and the CSST, but only one of these agencies will pay an indemnity.




                                                 17
                              Completing the Claim for Compensation form




                                        Bodily injuries
    7

◾       Describe injuries in your own words
        This description can include objects that struck you, the parts of the body
        that were injured as well as the type of injuries sustained (cuts, scratches,
        fractures, etc.).

          IMPORTANT : If, during your first medical consultation, the physician
          gave you the Initial Medical Report form, please send it to the Société.
          Medical information dated shortly after the accident is important for the
          processing of a claim for compensation.
          If the physician did not complete the form during your first consultation,
          the compensation officer shall discuss the matter with you when opening
          the case.
          Fees related to this report are reimbursed to the accident victim up to the
          maximum allowable amounts.




                                Social assistance (welfare)
11

        If you have checked off “yes”, the Ministère de l’Emploi et de la Solidarité
        sociale (MESS) may reimburse some of the expenses related to the accident.
        Please contact this government department first to claim those expenses.
        The SAAQ will then be able to reimburse you for expenses not covered by
        MESS.




                               Reimbursement of expenses
12

◾       Belongings damaged in the accident :
        You can immediately claim reimbursement for expenses already incurred
        due to the accident. If you have further expenses, you may claim them as
        they arise, providing they are accompanied with the relevant supporting
        documents.

          PLEASE NOTE: Do not forget to write your claim number or, if unavail-
          able, your health insurance number on every receipt or invoice you send
          to the SAAQ.



                                                 18
                     Completing the Claim for Compensation form




Prescription eyeglasses

◾ Replacement
  Only expenses for medically prescribed glasses will be reimbursed.
  Please enclose an invoice on which the cost of the lenses and frames,
  bought following the accident, are indicated separately, along with a
  copy of the prescription. For information on amounts payable, see the
  Compensation Table.

  NOTE: Eye examination fees may be reimbursed if not already covered by
  a social security plan.


◾ The purchases of eyeglasses due to the accident
  If the injuries sustained in the accident warrant the purchase of a pair of
  glasses, it is best to submit an estimate to the SAAQ before incurring
  costly expenses. A medical prescription indicating the relation between
  the injuries sustained and the purchase of a pair of glasses should be
  sent to the SAAQ.

  NOTE: Eye examination fees may be reimbursed if not already covered by
  a social security plan.


Contact lenses
To qualify for reimbursement, you must supply a detailed invoice and a copy
of the prescription. For information on amounts payable, see the
Compensation Table

Orthotic devices and prostheses (dentures, etc.)
Expenses incurred for the purchase, rental, repair, fitting or adjustment of
orthotic devices or prostheses you were wearing and which were damaged
in the accident can be immediately reimbursed.

◾ Replacement
  For the replacement of a dental prosthesis, it is best to submit an esti-
  mate to the SAAQ before incurring any costly expenses. Do not forget to
  ask your dentist or denturist to indicate the treatment codes applicable.
  The maximum amounts reimbursable can vary from one type of pros-
  thesis to another, according to the regulations.
  Expenses for other types of prostheses or orthotic devices (i.e. hair-
  pieces, orthopedic footwear, etc.) which have been medically prescribed
  are reimbursable. To find out which ones, call the following telephone
  number: 1 888 810-2525.




                                        19
                          Completing the Claim for Compensation form




     ◾ The purchases of prostheses or orthotic devices due to the accident
       If the injuries sustained in the accident warrant the purchase of a pros-
       thesis or an orthotic device, it is best to submit an estimate to the SAAQ
       before incurring costly expenses. A medical prescription indicating the
       relation between the injuries sustained and the purchase of the prosthe-
       sis or orthotic device should be sent to the SAAQ.

     Clothes
     Identify any damaged clothing.

     ◾ Cleaning and repair expense
       Priority goes to the cleaning and repair of clothing that was worn and da-
       maged in the accident. For a reimbursement of cleaning and repair expen-
       ses, submit the original invoices or receipts to the SAAQ.

     ◾ Replacement
       If your clothing had to be replaced because it was damaged beyond repair
       and cleaning, attach a receipt for any article you had to buy because of the
       accident.
       A helmet worn by a cyclist, motorcyclist or moped rider could qualify for
       reimbursement if it was damaged in the accident.
       The SAAQ reserves the right to have a damaged helmet or clothing checked,
       so keep those items until a decision on the claim has been rendered.
       PLEASE NOTE: Watches, jewellery and handbags are not covered under the
       Automobile Insurance Act.
       For information on amounts payable, see the Compensation Table.



13

◾    Expenses incurred in connection with the accident :
     You can immediately claim reimbursement for expenses already incurred
     due to the accident. If you have further expenses, you may claim them as
     they arise, providing they are accompanied with the relevant supporting
     documents.

       PLEASE NOTE: Do not forget to write your claim number or, if unavail-
       able, your health insurance number on every receipt or invoice that you
       send to the SAAQ.




                                             20
                     Completing the Claim for Compensation form




The purchase of medication
You can only claim the medication you had to purchase because of the acci-
dent. All types of prescribed medication are reimbursable as long as there is
an established link between this medication and the injuries sustained in the
accident. For a refund, please attach your invoices or receipts and indicate:
• the name of the medication
• the prescription number
• the date
• the amount

  NOTE: The amount you pay for medication will be reimbursed. Under cer-
  tain conditions some non-prescription medication may qualify for reim-
  bursement.


The purchase of medical dressings
You can only claim the medical dressings that you had to buy because of the
accident. Medical dressings are articles used to dress an injury, to protect
against infection and to promote healing. For a refund, please attach your
invoices or receipts and indicate:
• the type of bandage bought
• the date
• the amount
Also included under the classification of medical dressings are:
• Compresses            • Support hose
• Gauze                 • Adhesive tape, Micropore
• Wadding               • “Jobst” or “Dr. Gibaud” clothing, etc.
• Bandages

Fee for a medical report
Fees charged by a doctor or a dentist for a report needed for processing
your claim are reimbursable to the maximum amount upon presentation of
a receipt.
For information on amounts payable, see the Compensation Table.




                                        21
                      Completing the Claim for Compensation form




Care expenses
The accident victims who are no longer able, due to the accident, to take
care of a child under 16 years of age or of a disabled person who was being
looked after at the time of the accident are entitled to reimbursement.

   PLEASE NOTE: Only the additional care expenses incurred because of
   the accident can be reimbursed.

These expenses are reimbursable under the following conditions:
• The accident victim has a job or jobs totalling at least 28 hours a week or
  is 16 years of age and older and attends an educational institution full
  time.
• The spouse of the accident victim is unable to take care of the children (or
  disabled person) the accident victim was looking after.
For reimbursement of care expenses, forward the invoices or receipts given
by the person you paid to look after the children or disabled person.
For information on amounts payable, see the Compensation Table.

Home care assistance
Expenses incurred for personal assistance in the home may be reimbursed
if, due to the accident, the victim is unable to take care of himself/herself and
carry out basic daily activities (for example: getting out of bed, getting
dressed, preparing meals, etc.).
To find out if you are eligible for this type of assistance, inform the SAAQ of
your needs so that it can assess the situation and determine the weekly
amount to which you may be entitled.
For information on amounts payable, see the Compensation Table.

Availability allowance
When an accident victim requires medical treatment, an allowance can be
given to the person who escorts the victim or who needs to be present if the
victim’s health or age require it. To be eligible for this allowance, the person
assisting the victim must provide a statement specifying the reason for
accompanying the victim or for being present, and the duration.
If these expenses have already been paid, see page 24, Travel expenses
incurred by reason of the accident.
For information on amounts payable, see the Compensation Table.




                                         22
                       Completing the Claim for Compensation form




Other expenses
◾ Professional fees
  The SAAQ reimburses professional fees according to certain criteria.
  Only health care and treatment dispensed by a doctor, optometrist, den-
  tist or other professional regulated by the Professional Code, and by pre-
  scription by a physician, is reimbursable.
  •   acupuncturist                          •   optician
  •   audiologist                            •   speech therapist
  •   audioprosthesist                       •   pharmacist
  •   chiropractor                           •   physiotherapist
  •   dental hygienist                       •   dental technician
  •   denturist                              •   psychoeducator
  •   dietician                              •   psychologist
  •   guidance counsellor                    •   podiatrist
  •   nurse                                  •   X-ray technician
  •   nursing assistant                      •   medical technologist
  •   occupational therapist                 •   midwife
  •   respiratory therapist                  •   social worker

  PLEASE NOTE: Algotherapy, auriculotherapy, balneotherapy, homeopa-
  thy, iontophoresis, oligotherapy, orthotherapy, phytotherapy, prolothera-
  py and radiesthesia are not recognized by the medical profession and do
  not qualify for fee reimbursement.

  For reimbursement, please attach you invoices or receipts indicating:
  • the name of the professional
  • the type of treatment
  • the number of treatment sessions or the duration of the treatment
  • the cost of fees
  When required, supply a copy of the prescription. To find out the maxi-
  mum amounts reimbursable, see the Compensation table.
  Care or treatment received outside Québec is reimbursable in certain
  cases. Your compensation officer can inform you about the conditions
  that apply. For information on how such expenses are reimbursed, see
  page 14, Location of accident.




                                          23
                           Completing the Claim for Compensation form




     ◾ Hospital room
       Expenses incurred for private or semi-private hospital rooms are reim-
       bursable if the health of the accident victim requires such a room by pre-
       scription. A prescription attesting to the need for a private or semipri-
       vate room must be submitted before such a room can be allocated.

       PLEASE NOTE: Fees are generally covered by the Québec Hospital
       Insurance Plan as stated above. The claim must therefore be addressed to
       the Régie de l’assurance maladie du Québec.

       In the event of an accident occurring outside Québec, hospitalization
       expenses may be reimbursed. For information on how such expenses are
       reimbursed, see page 14, Location of accident.

     ◾ Transportation by ambulance
       Usually, the invoice for ambulance transportation in Québec is sent
       directly to the SAAQ by the ambulance company. However, if you
       received an invoice for such expenses, you can receive a refund for the
       cost of transportation from the scene of the accident to a hospital. Please
       enclose your receipt.
       For all other types of transportation by ambulance, please fill in Form
       Schedule 5 – Expenses for Travel to Receive Care and send us the
       prescription.

     ◾ Other expenses
       You may be reimbursed for several other types of expenses. If any other
       expenditure was necessary because of the accident, you may telephone
       the SAAQ at the number 1 888 810-2525 to find out whether it is covered
       by the plan and for information on the conditions for reimbursement,
       where applicable.




14
◾    Travel expenses incurred by reason of the accident
     Expenses for travel in order to receive health care or treatment are reim-
     bursable on presentation of receipts. Expenses for transportation by private
     automobile qualify for reimbursement, as do charges for parking and road
     tolls. However, taxi fares are reimbursed only where public transit does not
     serve the route that must be taken or where your condition does not allow
     you to use it.
       PLEASE NOTE: If several journeys are needed for treatment, please com-
       plete Schedule 5 – Expenses for Travel to Receive Care.




                                              24
                           Completing the Claim for Compensation form




     In addition, if this travel obliges you to pay for an overnight stay or for
     meals, these expenses may be reimbursed upon presentation of invoices or
     receipts, up to the prescribed maximum. To find out what the maximum is,
     contact the SAAQ at the following number: 1 888 810-2525.




                                         Signature
15
     The accident victim must personally sign the form and other documents,
     where applicable. If the victim is a minor (not yet 18 years old) or if he/she
     is unable to fill out the Claim for Compensation, the victim’s agent may sign
     the form and the other documents. The signature on the Claim for
     Compensation is also a pledge that the information supplied in the
     appended forms, where applicable, is correct.

       NOTE: From January 1, 1994, under Québec’s Civil Code the father and
       mother of a minor are automatically that person’s legal guardians, without
       any other formality. If only one parent signs a claim form, he/she is con-
       sidered by the Société to have the other’s consent to act as sole guardian
       and to seek compensation on behalf of both parents. The Public Curator is
       responsible for supervision of the administration of tutorships and cura-
       torships. As such, he is authorized to examine the payment of sums to
       guardians and trustees, in compliance with section 12 of the Public
       Curator Act.

     If the signatory to the claim form is the victim’s guardian or trustee
     designated by a court decision, this person must enclose with the form the
     judgement certifying that he/she may legally act as such.

     If your form is not signed, it will be returned to you, which means an
     unnecessary delay in processing your claim.




                  Authorization to disclose medical information
16
     Under the Automobile Insurance Act, the SAAQ requires your written
     consent to disclose medical information to your attending physician or
     another health care professional. Accordingly, you must fill out and sign
     the authorization form.




                                              25
                                       Completing the Claim for Compensation form




                                            Direct Deposit request
17
     Through direct deposit, the Société de l’assurance automobile du Québec
     (SAAQ) can deposit compensation payments directly to your bank
     account (in Canada only).
     To avail yourself of direct deposit, check off “yes” to the question: Do you
     want to use direct deposit? and provide the information for your account.
     Enclose a cheque marked “SPECIMEN” across it, do not staple.

        IMPORTANT : The SAAQ is required, in making a direct deposit, that
        this be done into an account in the accident victim’s name. No deposit
        can be made into a joint account. In the case of an victim who is a
        minor, an account in the accident victim’s name must be opened by a
        parent.


◾    Branch No., Institution No., Account No.


                                                                    en
       Jean Martin                                                                           folio 999 999 9   1
       123, rue Principale



                                                                 im
       Saint-Jean (Québec)   A1B 1C2




                                              pec
       Payez à l’ordre de                                                                $



         999                 99999 999
                                            S                        999 999 9
                                                                                                    /100 DOLLARS
                                                                      }
                              }
         }


                                               }



       Cheque no.              Branch No.      Institution No.        Account No.
       Not always shown        (5 digits)      (3 digits)             (max. 12 digits)
       on a cheque
       (Do not enter)




     Should direct deposit not be possible, payment is made by cheque.

        NOTE : A direct deposit request may be cancelled or changed at any time
        by telephoning the person assigned to the claim at the SAAQ.




                                                            26
                               Completing the appendices




                                     III
                            COMPLETING
                         THE APPENDICES




                              Victim’s situation
A

◾   Spouse at the time of the accident
    A spouse is defined as:
    • a person who, at the time of the accident, was living with, and married to
      or joined in civil union with the victim.
    • a person who, at the time of the accident, was living with the victim as
      though married and publicly represented as spouse for at least three
      years.
    • a person who, at the time of the accident, was living with the victim as
      though married and publicly represented as spouse for at least one year:
      – if a child has been born or is to be born of their union;
      – if they have adopted a child together;
      – if one of them has adopted one or more of the other’s children.




B

◾   Former spouse at the time of the accident
    A former spouse is defined as:
    • The person who is legally separated or divorced from the victim and who,
      at the time of the accident, was entitled to receive support from the vic-
      tim by virtue of a judgment or agreement (excluding child support).




                                         27
                                Completing the appendices




C

◾   Dependants at the time of the accident
    A dependant is defined as:
    • A minor child of the victim (under age 18) whether adopted or biological,
      and a minor person to whom the victim stood in loco parentis (acted as
      parent) at the time of the accident.

    Is also considered to be a dependant:
    • The victim’s child who had reached the age of majority or a person of age
      to whom the victim stood in loco parentis (acted as parent) at the time of
      the accident and any other person related to the victim by blood or adop-
      tion, if at the time of the accident, the victim was providing for more than
      50% of that person’s basic living needs.
      List the names and other contact information of:
      – dependants under age 18 at the time of the accident;
      – dependants between the ages of 18 and 25 years who attended an edu-
        cational institution full time at the time of the accident;
      – disabled persons who were your dependants at the time of the accident.
      – a person for whom the victim was providing for more than 50% of that
        person’s basic living needs.

      NOTE: If at the time of the accident you had more than six dependants,
      please provide the same information on a separate sheet of paper and
      attach it to the form, making sure to indicate your claim number or, if
      unavailable, your health insurance number.




                                          28
                                Completing the appendices




                              Economic situation
D
◾   Employment
    • If you were employed as a salaried worker at the time of the accident, you
      must answer all the questions. Your answers will help determine the
      amount of the income replacement indemnity you may be entitled to
      receive if you are unable to work because of the accident.

      PLEASE NOTE: Remember to enclose Form Schedule 2 – Attestation
      of Income by the Employer, to be completed by your employer and
      enclosed with your claim only if the period during which you were unable
      to work lasted more than seven days.

    • If you are self-employed, and you were disabled beyond seven days after
      the accident, you must supply, for the three previous years:
      – your provincial or federal income tax return (the provincial income tax
        return is preferred for Québec residents) and your notice of assess-
        ment; AND
      – one of the two following forms: TP-80-V Income and Expenses Relating
        to a Business or Profession or T2124 Statement of Business Activities or
        the statement of operating results (income and expenses): OR
      – for a non-resident of Canada, any official document attesting to income.
        This type of document is generally required by the fiscal authority of the
        country or territory concerned (equivalent to Revenu Québec or the
        Canada Revenue Agency).

      NOTE: Remember to indicate your claim number or, if unavailable, your
      health insurance number on each separate sheet you submit with the
      claim.




E
◾   At the time of the accident:

    Were you working without pay in a family business?
    • The accident victim whose situation corresponds to the following has the
      right to be reimbursed for the cost of the work performed:
      – a person who was working in a family business at the time of the acci-
        dent (by family business we mean any business that employs a blood
        relative or relative by adoption or marriage, regardless of legal status,
        e.g. company or partnership, registered or unregistered);
      – the accident victim worked without pay for the enterprise;
      – due to the accident the victim is unable to perform his/her usual work;
      – due to the accident, the victim has incurred employment expenses in
        order to be replaced.



                                          29
                                Completing the appendices




    • Salary expenses are reimbursed when presented with evidence of pay-
      ment. To be reimbursed, attach receipts and invoices indicating the fol-
      lowing:
      – the full name and address of the person who provided services;
      – the period of time covered by the request for reimbursement;
      – the amount paid or invoiced for services.
    • The request for reimbursement cannot be made for more than 180 days
      after the accident.
    For information on amounts payable, see the Compensation Table.

    Were you receiving employment insurance benefits or an
    employment assistance allowance?
    The accident may cause the loss of regular employment insurance benefits
    or an employment assistance allowance. Depending on the case, the Société
    will decide the amount of compensation for these losses.

    • If you were receiving regular employment insurance benefits at the time
      of the accident, ask the staff at your local Human Resources Canada
      Centre to complete Schedule 3 – Confirmation of employment insur-
      ance benefits lost due to the accident / Confirmation of an employment
      assistance allowance lost due to the accident, only if the periode during
      which your disability lasted more than seven days.

    • If you were receiving an employment assistance allowance as part of
      active measures by Employment Québec at the time of the accident, ask
      the staff at your centre local d’emploi du Québec to complete Form
      Schedule 3 – Confirmation of employment insurance benefits lost due
      to the accident / Confirmation of an employment assistance allowance
      lost due to the accident, only if the period during which your disability
      lasted more than seven days.

      PLEASE NOTE: Loss of both types of benefits due to an accident is pos-
      sible, in which case the form must be completed by both these centres.




◾   At the time of the accident, had an employer promised
    you a job?
    If an employer had offered you a job that you would have had if the accident
    had not occurred, provide the name and telephone number of this em-
    ployer.

      PLEASE NOTE: If seven days after the accident you are still incapacitat-
      ed or if you became incapacitated seven days after the accident, complete
      the Confirmation of Hiring form by telephoning the SAAQ at the fol-
      lowing number: 1 888 810-2525.




                                          30
                                Completing the appendices




F

◾   At the time of the accident, were you unable to work
    for a reason other than the accident?
    It may be that at the time of the accident you had already been unable to
    work either temporarily or permanently due to a work-related accident or
    sick leave for medical reasons.


◾   Describe your disability prior to the accident
    Describe any disability or disease you had before the accident and due to
    which you were unable to work. Indicate the name of the hospital or medi-
    cal clinic where you were treated as well as the name of the physician con-
    sulted.




H

    Fill out this section if you did not have a full-time job for at least a year
    when the accident occured.

◾   Education
    Circle only your last year of schooling and indicate the highest diploma or
    degree level received.


◾   In the five years before the accident, were there periods when:
    Your main occupation was taking care of a child under 6 years of
    age without pay?
    If you were looking after someone else’s child, please indicate, in addition to
    the information requested, the child’s name, date of birth and the reason for
    taking care of the child. Write this information on a separate piece of paper
    and attach it to the form. Remember to indicate your claim number or, if
    unavailable, your health insurance number.




                                          31
                                 Completing the appendices




    You were unable to hold a job due to illness, accident, etc.?
    If you answer “yes” to this question, please indicate the dates of the
    period(s) when you were unable to work and why (type of illness, disability
    or accident).


◾   Professional qualifications
    A certificate of qualification is the basic document a worker must have in
    order to practice a trade. For this qualification to be taken into considera-
    tion, your certificate must have been valid at the time of the accident. The
    same applies to professional associations of which you were a member in
    good standing on the day the accident took place.


◾   Employment history
    Please report all the jobs in the grid you held, beginning with the most
    recent one. This information will help the SAAQ determine employment
    and the amount of income replacement indemnity you are entitled to.
    If you have not worked in the past five years, please indicate the last three
    jobs and their duration.

      NOTE: Use a separate sheet of paper and attach it to the claim form if nec-
      essary. Remember to indicate your claim number or, if unavailable, your
      health insurance number.




                                           32
                                 Completing the forms




                                     IV
                             COMPLETING
                               THE FORMS


Schedule 2
◾   Attestation of Income by the Employer
    The form must be completed by your employer if you are in one of the fol-
    lowing situations:
    • You had a full-time or part-time job and you are still disabled seven days
      after the accident.
    • You had a job but were temporary incapable of working before the acci-
      dent and you are still disabled seven days after the accident.
    The Attestation of Income by the Employer must be sent within six days
    of the request from the SAAQ.

      PLEASE NOTE: Remember to complete the first part of the form entitled
      Identity of the victim.




Schedule 3
◾   Confirmation of employment insurance benefits lost due
    to the accident / Confirmation of an employment assistance
    allowance lost due to the accident
    The form must be signed by:
    • Your local Human Resources Canada Centre if you have lost your regular
      employment insurance benefits after the accident and you are still dis-
      abled seven days after the accident.
    • Your Centre local d’emploi du Québec if you lost your employment assis-
      tance allowance after the accident and you are still disabled seven days
      after the accident.

      NOTE: Loss of both types of benefits due to an accident is possible, in
      which case the form must be completed by both these centres.

      PLEASE NOTE: Remember to complete the first part of the form entitled
      Identity of the victim.



                                         33
                                  Completing the forms




Schedule 4

◾   Attestation of School Attendance
    The form must be signed by the educational institution when the accident
    victim is a full-time student aged 16 years or more.

      PLEASE NOTE: Remember to complete the first part of the form entitled
      Identity of the accident victim.




Schedule 5

◾   Expenses for Travel to Receive Care
    To claim fees for travel to receive care or treatment:
    • Provide the information requested;
    • Enclose the original receipts, where applicable.
    Expenses for transportation by private automobile qualify for reimburse-
    ment. However, taxi fares are reimbursed only where public transit does
    not serve the route that must be taken or where your condition does not
    allow you to use it.

    Details of transportation
      Reason for travel
      Specify the reason for travel.

      Means of transportation
      Use the letters to identify the means of transportation used:
         A :     Automobile
         C :     Public transit
         I   :   Bus, plane, train
         T   :   Taxi

      Round-trip distance
      If you used an automobile, indicate the number of kilometers from your
      residence to the place of consultation.

      Parking
      Write in the amount paid for parking and enclose the receipt(s).



                                          34
                                 Completing the forms




      Amount claimed
      If you used an automobile as a means of travel, you do not have to write
      in the amount claimed. This amount will be calculated on the basis of the
      distance indicated.
      On the other hand, if you used another means of transportation, enclose
      the receipt and write in the amount.

      Meals and lodging
      Where the cost of meals or an overnight stay were incurred to receive care,
      enter this on the back of the form in the space provided and specify the
      reason for travel. You must also enclose the original invoices or receipts.

      PLEASE NOTE: Remember to complete the first part of the form entitled
      Identity of the accident victim.




Schedule 6
◾   Job Description
    The form must be completed by your employer if you are in one of the fol-
    lowing situations:
    • You had a full-time or part-time job and you are still disabled seven days
      after the accident.
    • You had a job but were temporary incapable of working before the acci-
      dent and you are still disabled seven days after the accident.
    The Job Description must be sent within six days of the request from the
    SAAQ.

      PLEASE NOTE: Remember to complete the first part of the form entitled
      Identity of the accident victim.




                                         35

				
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