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					                                                       Claim for Compensation

                                                                                                                  Claim number                                                 Page         1/8
                                                                                Identity of the accident victim
       Québec driver’s licence number                                  Social insurance number                 Health insurance number
 1
       Last name at birth                                                                                                                         Sex
                                                                                                                                                  □ Female □ Male
       First name                                                                                                                                 Date of birth
                                                                                                                                                        Year        Month     Day


       Present last name if different from name at birth


       Civil status at the time of the accident                                                                                                                      Language of correspondence
                                                           □ Married or          □ Common law arrangement □ Widow(er) □ Legally separated
                                                               in civil union    □ Single                 □ Divorced □ De facto separation                           □ French □ English
                                                                                   Accident victim’s address
       Number                               Street                                                                                                                Apartment         P.O. Box
 2
       City or town / municipality                                                                                                  Province or state


       Country                                                                                                                      Postal code


       Telephone (home)                              Telephone. (at work)                                     Telephone (other)
        Area code                                    Area code                               Extention



                                                                                                  Accident
       Date and time of accident                                                You (accident victim) were:
 3            Year       Month        Day      Hour        Minute   □ AM 	
                                                       :            □ PM □ The driver             □ A passenger           □ A pedestrian       □ A cyclist
       Type of vehicle

       □ Car, pickup,       □ Truck           □ Motorcycle                              □ Other, specify:
           minivan          □ Bus             □ Moped, motorized scooter
        Licence plate number                                        Province, state or country


       Location of accident (city or town / municipality)                                                                 If outside Québec, indicate province, state or country



       Was a vehicle registered outside Québec involved in the accident?                           □ Yes        □ No          □ Don’t know
       Give a detailed account of facts relating to the accident (If space is insufficient, use a separate sheet)
 4




                                                                                         Accident report number. (if known)                              If accident occurred outside Québec, submit
 5                                                                                                                                                       a copy of the accident report in your posses-
       Was an accident report drawn up by a police officer?	               □ Yes ▶                                                                       sion, if any.
       	                                                                   □ No 	 □ Don’t know
       Was a Joint Report of the accident drawn up?	                       □ Yes (Enclose a copy) □ No □ Don’t know
       Did anyone witness the accident?	                                   □ Yes □ No
                                                                                  ▶




                                                                           (If yes, please provide the following information)                     Telephone
        Last name of witness                                                                                                                        Area code


        First name


        City or town / municipality                                                                                                                               DO NOT WRITE HERE


       Did the accident occur:
 6
       In the context of work                                         □ Yes         □ No
       Victims of a criminal act                                      □ Yes         □ No
       While assisting a person in distress

7383A 40 (2010-12)
                                                                      □ Yes         □ No
                                                                                                                                                                                                  DI
                                                                                                            Claim number                                                    Page           2/8
                                                                                        Bodily injuries
 7     Were you injured in the accident?	                                                             □ Yes                     □ No         (Go on to section 10)
       Did you hit your head or suffer a head or facial injury?	                                      □ Yes                     □ No
       Did you lose consciousness (not simply confusion or forgetfulness                              □ Yes                     □ No
       about the accident)?
       Since the accident, have you experienced problems:
       •	 in	the	area	of	the	head	or	face,	such	as	headache,	dizziness,	memory	loss,	                              □ Yes        □ No
          difficulty in concentrating, giddy spells?
       •	 in	the	area	of	the	neck:	pain	or	difficulty	in	neck	movements?	                                          □ Yes        □ No


       Please describe, in your own words, the injuries you sustained (cuts, scratches, contusions, pain, etc.) and send the Initial Medical Report form to the Société. For more
       information on the subject, consult page 18 of the guide.




                                                                                                                                                                              (If space is insufficient,
                                                                                                                                                                              use a separate sheet)
       After the accident, did you go to:                                             First
 8                                                                                    medical
                                                                                                      Year             Month     Day
       □ A hospital?                                                                  consultation
       □ A medical clinic?                                                           Physician’s name
       □ A doctor’s office?
       □ Another health care
           facility, specify:                                                        Name of health care facility


                                                                                     City or town / municipality
       □ No medical consultation took place

 9     Do the injuries resulting from the accident prevent you from resuming your occupation, studies or normal activities?

       □ Yes     ▶
                       Describe the tasks or activities        □ Hold employment                □ Care for children or a disabled adult
                       you can no longer perform:              □ Continue studies               □ Perform household chores
       □ No
                                                    Year        Month      Day        Date of planned                          Year          Month   Day
                       Date disability caused                                         resumption of work,
                       by the accident began                                          studies or normal activities


                                                                                      Resident status
10     At the time of the accident,             □ Yes      ▶   Licence plate
       did you (accident victim) own                           number
       a vehicle registered in Québec?          □ No
                                                                              Year          Month     Day                             Year       Month     Day
       Did you live outside Québec              □ Yes      ▶ From:                                                   To:
       during the twelve months
       prior to the accident?                   □ No                    City or town / municipality


                                                                        Province or state / country

       If yes:
            • Did you maintain                  □ Yes      ▶            City or town / municipality
              a permanent home
              in Québec?                        □ No
           •   If you stayed longer than six months
               outside Québec, give the reason(s):
       Were you a Canadian citizen              □ Yes                   Citizenship
       at the time of the accident?             □ No      ▶

                                                                         Social assistance (welfare)
11     At the time of the accident, were you (accident victim) or the person supporting you receiving social assistance (welfare)?	                      	 □ Yes     □ No
7383A 40 (2010-12)
                                                                                                         Claim number                                            Page              3/8
                                                                          Reimbursement of expenses
       •  YOU MAY CLAIM REIMBURSEMENT OF CERTAIN ACCIDENT-RELATED EXPENSES.
12     •  SEE PAGE 18 OF THE GUIDE TO FIND OUT IF YOUR EXPENSES QUALIFY AND WHICH SUPPORTING DOCUMENTATION MUST BE SUBMITTED WITH YOUR CLAIM.
       Belongings damaged in the accident:
       □ Prescription eyeglasses
       □ Contact lenses
       □ Dentures or other appliance            ▶	 Specify:

       □ Clothes      ▶	 Describe the damage to each item:




                                                                                                                                                                      (If space is insufficient,
                                                                                                                                                                      use a separate sheet)



13     Expenses incurred in connection with the accident:

       □ The purchase of medication       □ Availability
       □ The purchase of medical dressings allowance ▶	 Name of accompanying person:
       □ Fee for a medical report
       □ Care expenses                    □ Other expenses	 ▶	 Specify:
       □ Home care assistance
14     Travel expenses incurred by reason of the accident — transportation, lodging, meals:           □ Yes □ No         ▶	 Go on to section 15
                 Date of travel                   Round-trip       Other means of    Amount claimed                                                Medical consultations
                                               distance in km      transportation (enclose receipts other Lodging, meals
             Year         Month      Day       (if automobile)     or parking fees than for public transit) (enclose receipts)          Location                    Reason




                                            Remember to enclose bills or receipts, with the claim number written on each.

                                                                                               Signature
15     I certify that the information provided on this claim form is true. In the event that    SIGNATURE OF THE ACCIDENT VICTIM OR THE VICTIM’S AGENT
       further information is required for obtaining compensation and establishing its
       amount, I hereby authorize the Société de l’assurance automobile du Québec
       to obtain this information, in accordance with section 83.17 of the Act, from the
                                                                                                                                                             Date
       appropriate bodies such as the Régie des rentes du Québec, the Commission                                                                                    Year        Month      Day
       de la santé et de la sécurité du travail, the Régie de l’assurance maladie du
       Québec, etc.                                                                             X
       If this claim form is signed by the agent, please indicate in what capacity you are acting and provide the following information:
       □ Father or mother of a minor                    □ Designated guardian of a minor or trustee          □ Other, specify:
                                                            (enclose a copy of the judgment)
                     Last name of agent
       □ Mr.
       □ Ms.
       First name


       Address (if it is different from that of the victim)                                                                                         Apartment              P.O. Box
       Number                              Street


       City or town / municipality                                                                                        Province or state


       Country                                                                                                            Postal code


       Telephone (home)                             Telephone (at work)                              Telephone (other)
        Area code                                   Area code                           Extention

7383A 40 (2010-12)
                                                                                                        Claim number                                          Page            4/8
                                                         Authorization to disclose medical information
16     Accident victim’s last name at birth



       First name



       Present last name if different from name at birth                                                                          Health insurance number




       Authorization to convey medical information to attending physician or health care professional
       I hereby authorize the assessing physician, health care professional, rehabilitation counsellor and compensation officer of the
       Société de l’assurance automobile du Québec to convey medical information regarding my health, where appropriate, to my
       attending physician or to any other health care professional. I understand that a written summary of an oral communication will
       be entered into my claim file.

       A photocopy or a computerized reproduction of the authorization has same validity as the original, under Articles 2840 and 2841
       of the Civil Code of Québec.


                                                                         Signature of the accident victim or the victim’s agent


                                                                                                                                               Date
                                                                                                                                                      Year     Month    Day
                                                                         X

                                                                                   Direct Deposit
17     SEE GUIDE, P. 26 BEFORE FILLING OUT THIS SECTION.

       Do you want to use direct deposit?	               □ Yes   ▼	 Provide the following information
                                                         □ No
       Branch number                   Institution no.      Account number                                                          The numbers are shown on your cheques. If you do
                                                                                                                                    not have a cheque, your institution can provide the
                                                                                                                                    equivalent.
       Name of financial institution




       I authorize the Société de l’assurance automobile du              Signature of the accident victim or of one parent, in the case of an underage victim
       Québec (SAAQ) to deposit into the above-mentioned
       account the payments to my name. I also authorize
       the SAAQ to convey the information required for such                                                                                    Date
       deposit to the financial institution acting on its behalf                                                                                      Year     Month    Day
       and to mine.                                                      X

                                                         ENCLOSE A CHEQUE MARKED “SPECIMEN” ACROSS IT; DO NOT STAPLE.




                     Send to: Société de l’assurance automobile du Québec, Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2


7383A 40 (2010-12)
                                                    SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS
                                                                                                                                                                            Appendix
                                                                                                                                                          Victim’s Situation
                                                                                                    Claim number                                                 Page           5/8
       At the time of the accident, did you have a spouse*?         You were:
 A                                                                                                                                                               Year       Month
       □ Yes         □ No   ▶	 Go on to section B                   □ Legally married or in civil union          □ Living common-law          ▶	 Since:
                                                                                       Spouse’s last name at birth
       From this union:
       •		Had	a	child	been	born?	     	 □ Yes 	 □ No
                                                                                       First name
       •		Was	a	child	to	be	born?	    	 □ Yes 	 □ No
       •		Was	a	child	adopted
          by you and your spouse?	      	 □ Yes 	 □ No           If yes, provide        Sex                 Date of birth                      Health insurance number
                                                                 a copy of the                                   Year          Month    Day
       •		Was	a	child	of	one	spouse                              adoption order            □ Female
          adopted by the other?	         □ Yes 	 □ No                                      □ Male
       Did your spouse live at the same address as you at the time of the accident?	     □ Yes □ No                     Is your spouse disabled?	     □ Yes □ No
       At the time of the accident, did you have a former spouse*?
 B                                                                      Were you paying or required to
                                                                                                             □ Yes      ▶	     Indicate the yearly amount?
                                                                                                                                                              $
                                                                        pay support in accordance with
       □ Yes         □ No   ▶	 Go on to section C                       a judgment or an agreement?          □ No              Attach a copy of the official document stating this
                                                                                                                               amount
       Former spouse’s last name at birth                                                                                    Sex                            Date of birth
                                                                                                                                                                 Year       Month   Day
                                                                                                                             □ Female □ Male
       First name



       *Spouse refers to either a man or a woman of the same or opposite gender.

 C     Did you have any dependant(s) at the time of the accident?       □ Yes       □ No    ▶	 Go on to section D

         FOR EVERY CHILD OR PERSON CONSIDERED YOUR DEPENDANT AT THE TIME OF THE ACCIDENT, PLEASE PROVIDE THE INFORMATION SOUGHT.


    1. Last name                                                                                                             Sex                            Date of birth
                                                                                                                                                                 Year       Month   Day
                                                                                                                             □ Female □ Male
       First name


       Health insurance number                      Relation to you
                                                       Biological      Spouse’s        Other,
                                                       child           child           specify:
       Level of education in progress                                              □ General
                                        □ Elementary     	 □ Secondary             □ Vocational            □ College         	 □ University       	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                                  Is this person                                  Was this person
       insurance, etc.)               $                                                disabled?	 	       □ Yes □ No                   living with you?	   	 □ Yes □ No
   2. Last name                                                                                                              Sex                            Date of birth
                                                                                                                                                                 Year       Month   Day
                                                                                                                             □ Female □ Male
       First name


       Health insurance number                      Relation to you
                                                       Biological      Spouse’s        Other,
                                                       child           child           specify:
       Level of education in progress                                              □ General
                                        □ Elementary     	 □ Secondary             □ Vocational            □ College         	 □ University       	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                                  Is this person                                  Was this person
       insurance, etc.)               $                                                disabled?	 	       □ Yes □ No                   living with you?	   	 □ Yes □ No
   3. Last name                                                                                                              Sex                            Date of birth
                                                                                                                                                                 Year       Month   Day
                                                                                                                             □ Female □ Male
       First name


       Health insurance number                      Relation to you
                                                       Biological      Spouse’s        Other,
                                                       child           child           specify:
       Level of education in progress                                              □ General
                                        □ Elementary     	 □ Secondary             □ Vocational            □ College         	 □ University       	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                                  Is this person                                  Was this person
       insurance, etc.)               $                                                disabled?	 	       □ Yes □ No                   living with you?	   	 □ Yes □ No



7383A 40 (2010-12)
                                                                                                                                                               Appendix
                                                                                                                                         Victim’s Situation
                                                                                               Claim number                                         Page           6/8

 C     DEPENDANTS (CONTINUED)

   4. Last name                                                                                                  Sex                           Date of birth
                                                                                                                                                    Year       Month   Day
                                                                                                                 □ Female □ Male
       First name


       Health insurance number                     Relation to you
                                                      Biological     Spouse’s      Other,
                                                      child          child         specify:
       Level of education in progress                                           □ General
                                        □ Elementary    	 □ Secondary           □ Vocational         □ College   	 □ University     	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                              Is this person                         Was this person
       insurance, etc.)               $                                            disabled?	 	     □ Yes □ No            living with you?	   	 □ Yes □ No
   5. Last name                                                                                                  Sex                           Date of birth
                                                                                                                                                    Year       Month   Day
                                                                                                                 □ Female □ Male
       First name


       Health insurance number                     Relation to you
                                                      Biological     Spouse’s      Other,
                                                      child          child         specify:
       Level of education in progress                                           □ General
                                        □ Elementary    	 □ Secondary           □ Vocational         □ College   	 □ University     	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                              Is this person                         Was this person
       insurance, etc.)               $                                            disabled?	 	     □ Yes □ No            living with you?	   	 □ Yes □ No
   6. Last name                                                                                                  Sex                           Date of birth
                                                                                                                                                    Year       Month   Day
                                                                                                                 □ Female □ Male
       First name


       Health insurance number                     Relation to you
                                                      Biological     Spouse’s      Other,
                                                      child          child         specify:
       Level of education in progress                                           □ General
                                        □ Elementary    	 □ Secondary           □ Vocational         □ College   	 □ University     	 □ Does not apply
       Gross annual employment income
       (including welfare, employment                                              Is this person                         Was this person
       insurance, etc.)               $                                            disabled?	 	     □ Yes □ No            living with you?	   	 □ Yes □ No

         IF YOU HAD ANY OTHER DEPENDANTS, PLEASE WRITE DOWN THE CORRESPONDING INFORMATION ON A SEPARATE SHEET OF PAPER AND ATTACH IT,
         REMEMBERING TO ENTER THE CLAIM NUMBER SHOWN ABOVE.




7383A 40 (2010-12)
                                                                                                                                                                       Appendix
                                                                                                                                              Economic Situation
                                                                                                   Claim number                                                Page         7/8

 D     Were you employed at the time of the accident?         □ Yes       □ No   ▶	 Go on to section E

         PROVIDE THE INFORMATION SOUGHT BELOW FOR EACH EMPLOYMENT POSITION.
       Name of employer or business                                                                                                               Telephone
                                                                                                                                                   Area code

       Date hired                        Expected end (if applicable)    Type of employment
             Year       Month    Day          Year       Month     Day   □ Full-time       □ Part-time         □ Temporary
                                                                         □ Other, specify:
       Number of hours                 Job title
       worked
       per week:
       Employment     □   Salaried         ▶	 Have Schedule 2 “Attestation of Income by the Employer” filled out if you were disabled beyond seven days after the accident.
       status
                      □   Self-employed ▶	 If you were disabled beyond seven days after the accident, you must supply, for the three previous years:
                                               – Québec resident
                                               	 □ Provincial income tax return, AND
                                               	 □ Notice of assessment, AND
                                               	 □ Form TP-80-V (Income and Expenses Relating to a Business or Profession) or □ Statement of operating results (income and expenses)
                                               – Canadian resident (outside Québec)
                                               	 □ Federal income tax return, AND
                                               	 □ Notice of assessment, AND
                                               	 □ Form T2124 (Statement of Business Activities) or □ Statement of operating results (income and expenses)
                                               – Non-resident of Canada
                                                 Any official document attesting to the income indicated by the self-employed worker required by the fiscal authority of the country or
                                                 territory concerned (equivalent to Revenu Québec or the Canada Revenue Agency).

       IF SPACE IS INSUFFICIENT, PLEASE PROVIDE THE SAME INFORMATION ON A SEPARATE SHEET WHICH YOU ATTACH TO THIS FORM AND HAVE SCHEDULE 2
       FILLED OUT. REMEMBER TO ENTER THE CLAIM NUMBER SHOWN ABOVE THIS PAGE. MAKE PHOTOCOPIES OF SCHEDULE 2 IF NEEDED.


 E     At the time of the accident:
       Are you registered as a full-time              □ Yes      ▶ If you were age 16 or older, have Schedule 4 “Attestation of School Attendance” filled out.
       student in an educational program?             □ No
       Were you working without pay                   □ Yes
       in a family business?                          □ No
       Were you receiving employment                  □ Yes      ▶ Have Schedule 3 “Confirmation of employment insurance benefits lost due to the accident / Confirmation
       insurance benefits or an employment            □ No         of an employment assistance allowance lost due to the accident” filled out if you were disabled beyond
       assistance allowance?                                       seven days after the accident.

       At the time of the accident, had an employer promised you a job?

       □ Yes     ▶     Name of employer or business                                                                                                   Telephone.
                                                                                                                                                      Area code
       □ No
            Please submit a “Confirmation of Hiring” form filled out and signed by the prospective employer if you were disabled beyond seven days after the accident.




7383A 40 (2010-12)
                                                                                                                                                                                        Appendix
                                                                                                                                                                Economic Situation
                                                                                                            Claim number                                                     Page             8/8

 F       At the time of the accident, were you unable to work for a reason other than the accident?                □ Yes	   	 	    □ No    ▶	 Go on to section G
                                                                                                                            Year           Month   Day
         You were unable to work:          □ Temporarily        □ Permanently                            Since?

         Describe your disability prior to the accident




 G       At the time of the accident, were you

         □ The recipient of a pension from the Commission de la santé et de la sécurité du travail             ▶ Your file number:

         □ The recipient of a disability pension under the Québec Pension Plan
         □ The recipient of a disability pension from another agency           ▶ Specify:

         □ Not receiving any pension

 H       IF YOU HAD NOT HELD FULL-TIME EMPLOYMENT FOR OVER A YEAR WHEN THE ACCIDENT OCCURRED, YOU MUST PROVIDE THE INFORMATION BELOW.

         Education                                                                                                                                       Year        Month
                             Elementary        1    2       3      4       5     6     7
         Please circle       Secondary         1    2       3      4       5                        Date full-time studies ended
         last level
         completed           College           1    2       3
                             University        Undergraduate       Graduate      Postgraduate       Diploma(s) obtained and specializations:

         In the five years before the accident, were there periods when:                     Year      Month                Year           Month
         Your main occupation was taking                                       from:                             to:
         care of a child under 6 years                     □ Yes       ▶
         of age without pay?                               □ No                                                                                                         Reason(s)
                                                                                             Year      Month                Year           Month
         You were unable to hold a job                                         from:                             to:
         due to illness, accident, etc.?                   □ Yes       ▶
                                                           □ No                              Year      Month                Year           Month

                                                                               from:                             to:
                                                                                             Year      Month                Year           Month

                                                                               from:                             to:


         Do you hold any certificates
         of qualification or professional licences?	                       □ Yes       □ No         If yes, specify:


         Are you a member of a professional association?	                  □ Yes       □ No         If yes, specify:

         Employment history         State all occupations or the last three (3) positions held if you did not work during the past five (5) years.
                                    This information is required to determine the amount of any entitlement.
                                    Keep all of your supporting documents so that you can provide them to us on request.
                                                                                                                                                                Number of hours
              Period worked                        Name of                                   Kind of                               Job                                                        Gross
               (starting with                                                                                                                              worked       ordinary work
                                                     firm                                   business                               title                                 week in the         income
               most recent)                                                                                                                               per week
                                                                                                                                                                          business
                Year        Month
 From:                                                                                                                                                                                  $
                Year        Month                                                                                                                                                           □ Per hour
  To:                                                                                                                                                                                       □ Per week
                Year        Month
 From:                                                                                                                                                                                  $
                Year        Month                                                                                                                                                           □ Per hour
  To:                                                                                                                                                                                       □ Per week
                Year        Month
 From:                                                                                                                                                                                  $
                Year        Month                                                                                                                                                           □ Per hour
  To:                                                                                                                                                                                       □ Per week
                Year        Month
 From:                                                                                                                                                                                  $
                Year        Month                                                                                                                                                           □ Per hour
  To:                                                                                                                                                                                       □ Per week
                Year        Month
 From:                                                                                                                                                                                  $
                Year        Month                                                                                                                                                           □ Per hour
  To:                                                                                                                                                                                       □ Per week
7383A 40 (2010-12)
                          OTHER

                       Forms

                     To be filled out
                         if required




7662A 40 (2005-09)
                                                 Attestation of income by the employer
                                                 Under the Act, an employer is required, at the Société’s request, to provide within six
                                                 (6) days an attestation of an employee’s earnings following that employee’s claim for
                                                 compensation from the Société.
                                                                                                                                                         Schedule 2
                                                                              Identity of the victim
                                                            To be filled out by the victim or by his or her agent
          Victim’s last name at birth
                                                                                                                                                         Date of the accident
          First name                                                                                              Social Insurance number                  Year       Month Day


          Address                                                                                                               Apartment
          Number             Street

          P.O. Box                              City / Municipality


          Province / State                                                                         Country                                                  Postal code



                                                                                           Employer
                                                  To be filled out by the employer if the victim is a salaried worker
          Employer’s name or business name

          Address
          Number             Street

          P.O. Box                              City / Municipality

          Province / State                                                                       Country                                                    Postal code


          Job title (Join a copy of the Job Description)                                                                 Date hired                Expected end (if applicable)
                                                                                                                     Year      Month    Day              Year      Month     Day




          Type of employment:                Full-time            Part-time               Temporary            Other regular remuneration that will not be                Annual
                                                                                                                     paid by reason of the accident                       amount
               Other, specify:
                                                                                                              Overtime worked on a regular basis
          Number of hours worked per week
          (in the case of employment on call, give the average                                                Allowances
          number of hours worked in the past year):                                          h

          Firm’s regular work week                                                                            Tips
          for a full-time worker with the same duties:                                       h
                                                                                                              Commissions
          Gross earnings:
                                               Hourly                 Weekly                     Yearly
          $                                    Other, specify:                                                Bonuses

                Date work ended as                               Actual date of resumption
               a result of the accident                                   of work                             Profit sharing
                Year       Month      Day                           Year          Month    Day
                                                                                                              Dividends paid in consideration for work
                                                                                                              performed

          At the time of the accident, was this person already disabled?                                      Cash value of the personal use of lodging or
                                                                                                              automobile supplied by the employer
              Yes            No        If yes, specify:
                                                                                                              Allowance for use of equipment and clothing
          Did the accident occur while the employee was
          carrying out his or her duties?                                    Yes             No
                                                                                                                                                            Total $

                                            Declaration                                                                        DO NOT WRITE IN THIS SPACE
 I certify that the above information is true and complete.
                                                                                           Date
 Employer’s signature                                                              Year       Month Day



 Name (in block letters)                                                                                     Claim number


 Title or function                                                    Telephone                              Send to:
                                                                      Area code                              Société de l’assurance automobile du Québec
                                                                                                             Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2
                                                                                                             By fax: 1 866 289-7952                                          AR
Société de l’assurance automobile du Québec
6016A 40 (2010-04)

                                                     SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS
                                              □ Confirmation of employment insurance benefits lost due to the accident
                                              □ Confirmation of an employment assistance allowance lost due to the accident
                                                                                                            Schedule 3
                                                                                Identity of the victim
                                                            To be filled out by the victim or by his or her agent
    Victim’s last name at birth

                                                                                                                                                                       Date of the accident
    First name                                                                                                                Social insurance number                       Year       Month     Day


    Address
    Number              Street                                                                                                               Apartment

    P.O. Box                              City / Municipality


    Province / State                                                                            Country                                                                       Postal code




    □ I hereby authorize Human Resources Development Canada to                                        □ I hereby authorize Employment Québec to provide the Société
         provide the Société de l’assurance automobile du Québec with                                      de l’assurance automobile du Québec with information.
         information.
         Signature of the victim or his or her agent                                                       Signature of the victim or his or her agent




                                                                                                       For loss of an employment assistance allowance
         For loss of employment insurance benefits
                                                                                                      as part of active measures by Employment Québec
                         Have this section filled out by the                                                                    Have this section filled out by the
                     local Human Resource Centre of Canada                                                                     local Employment Québec Centre
Number               Street                                                                           Number             Street


                                                                  P.O. Box                                                                                           P.O. Box


City / Municipality                             Province                  Postal code                 City / Municipality                                Province                  Postal code


                                                                                                      Type of
 Did the victim lose his or her entitlement to employment insurance                                   program
 benefits due to the automobile accident?

 □ Yes           □ No                                      Year          Month        Day             Did the victim lose his or her entitlement to an employment
                                                                                                      assistance allowance due to the automobile accident?
 If yes, enter the date when
 he or she became ineligible:                                                                         □ Yes          □ No
 How many weeks of regular benefits did the victim lose on account                                                                                       Year       Month      Day
 of the accident, including the first week of ineligibility?  weeks                                   If yes, enter the date when
                                                                                                      he or she became ineligible:
                                                                                                                                                         Year       Month      Day
                                                    Year        Month    Day
                                                                                                      Planned end allowance
 Planned end of benefits
                                                                                                      Indicate the gross weekly amount
 Gross weekly amount payable: $                                                                       payable excluding additional allowances: $

 LOCAL HUMAN RESOURCE CENTRE AUTHORIZED PERSON                                                        LOCAL EMPLOYMENT QUÉBEC CENTRE AUTHORIZED PERSON
 Signature                                                              Date                          Signature                                                              Date
                                                                               Year     Month   Day                                                                                 Year    Month      Day


 Name (in block letters) of the authorized person               Telephone                             Name (in block letters) of the authorized person              Telephone
                                                                Area code                                                                                           Area code



                                                                                                                            Claim number
                 DO NOT WRITE IN THIS SPACE

                                                                                                                            Send to:
                                                                                                                            Société de l’assurance automobile du Québec
                                                                                                                            Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2
                                                                                                                            By fax: 1 866 289-7952                                               AC
Société de l’assurance automobile du Québec
6017A 40 (2010-04)
                                                      SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS
                                                Attestation of School Attendance
                                                                                                                                                               Schedule 4
                                                For full-time students aged 16 or older

                                                                                                                                      Claim number

                                                                          Identity of the accident victim
                                                                 To be filled by the victim or by his or her agent
                                                                                                                                            Date of the accident
         Victim’s last name at birth                                                                                                          Year     Month    Day



         First name                                                                                                         Health insurance number

         Address                                                                                                                         Apartment
         Nunber             Street

         P.O. Box                               City / Municipality


         Province / State                                                                     Country                                                                 Postal code


         I hereby authorize the aforenamed educational institution to provide the So-               Signature                                                      Year      Month Day
         ciété de l’assurance automobile du Québec with the information it requires
         to establish my right to compensation.


                                                                                           Studies
                                                                   To be filled out by the educational institution
                                                   This form covers full-time students aged sixteen or older.
                                            It must not be used if the accident victim did not meet both conditions.
         Name of the educational institution


         Address
         Number             Street


         P.O. Box                               City / Municipality


         Province / State                                                                     Country                                                                 Postal code


         Please circle the level of the victim’s schooling at the time of the accident:
                High School     1    2      3      4      5               Regular stream        Occupational training (DEP)       General program for adults       Other (specify):
                College         1    2      3             University       Undergraduate             Graduate        Postgraduate


         Specify the program in which the victim was enrolled at time of the accident:
         Enter the date normally expected for graduation if                    Year       Month Day
         the accident had not occurred:                                                                         (Estimate the date for someone in a special path.)
         Have studies been resumed in full since                                      Year          Month Day           No, the projected date of                 Year      Month Day
         the accident?                                   Yes, since:                                                    return to studies (if known) is:
         Was this person enrolled in a course of studies given as part of active Employment
         Québec measures under the Employment Insurance Act?                                                          Yes        No

                                                       Declaration                                                       Seal of the institution

            I, the undersigned, do hereby declare at the time of the accident, the above-mentioned
            person was enrolled as a regular student in a secondary or postsecondary program on
            a full-time basis at our institution and met all attendance requirements.
            Signature of the authorized person                                                       Date
                                                                                             Year      Month Day

            X
            Name (in block letters) of the authorized person



            Title or function                                 Telephone                        Extention
                                                              Area code



                DO NOT WRITE IN THIS SPACE

                                                                                                                       Send to:
                                                                                                                       Société de l’assurance automobile du Québec
                                                                                                                       Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2
                                                                                                                       By fax: 1 866 289-7952                                         FS
Société de l’assurance automobile du Québec
6018A 40 (2010-04)
                                                     SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS
                                                                                                                                                                               Schedule 5
                                                   Expenses for Travel to Receive Care


                                                                                                                                                    Claim number



  • To claim expenses for travel to receive care or undergo treatment, please provide the information indicated below and
           submit original receipts for any payment made.
  • Expenses for transportation by private automobile qualify for reimbursement. 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.
  •        All travel expenses claimed must be related to injury sustained in the accident. Enter them in chronological order on the
           form.
  •        In order to speed up processing, please write your claim number.

                                                                                   Identity of the accident victim
                                                                                                                                                               Date of the accident
             Victim’s last name at birth                                                                                                                        Year     Month Day


            First name                                                                                                                       Health insurance number

             Address                                                                                                                                      Apartment
            Number              Street

             P.O. Box                               City / Municipality


             Province / State                                                                               Country                                                                   Postal code




                                                                        Cost of travel (enclose original receipts)
                                               A = Private automobile C = Public transit I = Coach, plane, train T = Taxi
                                                                                  Reason for travel (1)                                                          Round-trip
                    Date of travel                                                                                                                 Means of                                  Amount
                                                Physio- Occupational-   Chiro-      Psycho-   Acupunc-   Social
                                                                                                                   Visit your      Other                          distance    Parking
                                                                                                                  doctor or to                     transport       (km) (2)
                                                                                                                                                                                            claimed (3)
                  Year      Month        Day   therapist  therapist     practor      logist     turist   worker
                                                                                                                  go hospital    (specify)

      1
      2
      3
      4
      5
      6
      7
      8
      9
      10
      11
      12
      13
      14
      15
      16
(1)
    Reason for travel        — Specify the reason for travel.
    Round-trip distance (km) — Only the distance travelled by car.
                                                                                                                                                                                                          FJ
(2)
(3)
    Amount claimed           — If claiming travel distance in km, you need not enter the rate.
Société de l’assurance automobile du Québec
6019A 40 (2010-04)
                                                                                                                                                                                              (Page 1 of 2)
                                                                                                                                                              Schedule 5
                                                                                                                                              Claim number




                                                          Meals and lodging (enclose original receipts) (4)
                                                                         Reason for travel                                           Cost of meals and lodging (if justified)
                      Date                 Physio- Occupational-   Chiro-    Psycho-   Acupunc-   Social
                                                                                                            Visit your
                                                                                                           doctor or to   Other
               Year      Month    Day     therapist  therapist     practor    logist     turist   worker
                                                                                                           go hospital            Breakfast       Lunch      Dinner      Lodging

      1
      2
      3
      4
      5
      6
      7
      8
      9
      10
      11
      12
      13
      14
      15
      16
(4)
      Meals and lodging — Where the cost of meals or an overnight stay were incurred to receive care, enter this in the part of the form in the space
                          provided and specify the reason for travel. You must also enclose the original invoices or receipts.




                                          Declaration                                                                                          DO NOT WRITE IN THIS SPACE
 I certify that the information provided is accurate and complete

  Signature of accident victim or victim’s agent
                                                                                              Date
                                                                                       Year      Month       Day

 X




                                                                 ,
To get an additional copy of “Expenses for Travel to Receive Care” please contact the SAAQ by telephone at the number shown
on the acknowledgment of receipt letter sent to you, or go to: www.saaq.gouv.qc.ca and click on Formulaires électroniques,
then select English.




                      Send to: Société de l’assurance automobile du Québec, Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2


6019A 40 (2010-04)
                                                     SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS                                                                       (Page 2 of 2)
                                                                                                                                                    Schedule 6
                                              Job Description
                                                                                                                             Claim number


This form is used by the Société in determining the length of accident-related disability in connection with employment described
below. Please provide accurate information so that any ensuing decision is fair and complete. The Société reserves the right to
contact an employer for further details.
                                                                        Identity of the accident victim
                                                                                 Fill out this section
                                                                                                                                      Date of accident
         Victim’s last name at birth                                                                                              Year        Month Day


         First name




                                                                                   Employment
                                             Have this section filled out by your employer at the time of the accident
         Name of employer or business


         Address
         Number                  Street

          P.O. Box                                City / Municipality


          Province / State                                                               Country                                                          Postal code


             Title of position held at the time of the accident                                                 Date hired                    Expected end (if applicable)
                                                                                                         Year         Month     Day              Year        Month      Day


          Main duties of the position




         Would	you	accept	for	the	employee:	             •	 a	gradual	return	to	work?	       □	Yes       □	No
         	                                               •	 a	lighter	work	load?	            □	Yes       □	No
         Check off the personal qualities required for this job

         □	Independence, initiative, vitality                           □	Sense of responsibility
                                                                                                                        □	 Adapts easily, shows anwith others
                                                                                                                                                  open mind,
                                                                                                                           patience, good-natured
         □	Ability to criticize, analyze, synthesize                    □	Perseverance (vs easily gives up)
         □	Sense of organization and discipline                         □	Ability to handle stress                      □	 Communicates well, shows tact,
                                                                                                                           is discrete, courteous, persuasive
                                                                                                                                                                              IE
Société de l’assurance automobile du Québec
4822A 40 (2012-03)
                                                                                                                                                                  (Page 1 of 2)
                                                                                                                                               Schedule 6
                                                                                                                         Claim number

                                                                            Employment
  CHECK OFF THE PHYSICAL REQUIREMENTS FOR THIS JOB

  Physical abilities
  Vision
  □	Have a full visual field
  Limb coordination
  □	Coordinate upper limb movements              □	Coordinate upper and lower limb movements
  Senses
  □	Distinguish smells                □	Distinguish sounds                  □	Communicate orally
  Physical strength
  Lift a weight             □	up to 5 kg         □	up to 10 kg              □	of 10 to 20 kg                □	of 20 kg or more
  Body position
  □	Remain seated for lengthy periods            □	Remain standing or walk for lengthy periods              □	Work in uncomfortable positions
        Specify the portion of time spent in each position during a workday:
         Position       %             By intervals              By extended interval (>20 min.)                                     Specify
         Walking                 □	Yes        □	No               □	Yes          □	No
         Standing                □	Yes        □	No               □	Yes          □	No
         Seated                  □	Yes        □	No               □	Yes          □	No
        Repetitive or frequent movements:            % Specify:       □	neck         □	back       □	other:
  Physical surroundings
  Workplace location
  □	Indoors                  □	Outdoors
  Workplace conditions
  □	Temperature variations                  □	Cold                    □	Heat
  □	Noisy                                   □	Vibrations              □	Dusty
  Risks
  □	Risks to be avoided in the workplace, specify:
  Other requirements or characteristics associated with the position




                                                                             Declaration
 I certify that the above description corresponds to employment held at the time of the accident
 Employer’s signature                                                Date             Signature of the accident victim or the victim’s agent            Date
                                                              Year     Month   Day                                                               Year     Month   Day

 X                                                                                    X
 Employer’s name (in block letters)
                                                                                                                                 DO NOT WRITE HERE

 Title or function                                Telephone
                                                  Area code



                     Send to: Société de l’assurance automobile du Québec, Case postale 2500, succ. Terminus, Québec (Québec) G1K 8A2
                      By fax: 1 866 289-7952

4822A 40 (2012-03)
                                              SEND TO THE SOCIÉTÉ IN CARE OF THE ABOVE ADDRESS                                                           (Page 2 of 2)

				
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