Initial Claim Forms Package
The Settlement: Who is it for?
The 1986-1990 Hepatitis C Settlement Agreement is for the benefit of two main
• Persons who were infected with HCV for the first time through Blood
transfusions received in Canada during the period of January 1, 1986
to July 1, 1990, and certain members of their families; and
• Persons with certain congenital clotting deficiencies (hemophilia) or
Thalassemia Major who contracted HCV and received or took Blood
and Blood products in Canada during the period of January 1, 1986 to
July 1, 1990, and certain members of their families.
Types of Claimants
There are five types of claimants identified in each Plan. You must be one of
Transfused HCV Plan Hemophiliac HCV Plan
1. Primarily-Infected Person 1. Primarily-Infected Hemophiliac
2. Secondarily-Infected Person 2. Secondarily-Infected Person
3. HCV Personal Representative 3. HCV Personal Representative
They may represent: They may represent:
a deceased primarily-infected person a deceased primarily-infected person
or secondarily-infected person; or or secondarily-infected person; or
a living primarily-infected person or a living primarily-infected person or
secondarily-infected person who is secondarily-infected person who is
either a minor or an adult who is either a minor or an adult who is
mentally incompetent. mentally incompetent.
4. Family Member 4. Family Member
(Please Note: Family Members can make a (Please Note: Family Members can make a
Claim only if the HCV Infected Person is Claim only if the HCV Infected Person is
Family Members who may be entitled to Family Members who may be entitled to
payment under this Plan include the Spouse, payment under this Plan include the Spouse,
Child, Grandchild, Parent, Grandparent or Child, Grandchild, Parent, Grandparent or
Sibling of a HCV Infected Person. Sibling of a HCV Infected Person.
5. Dependant 5. Dependant
(Please note: Dependants can make a Claim (Please note: Dependants can make a Claim
only if the HCV Infected Person is deceased.) only if the HCV infected Person is deceased.)
A Dependant may include the Spouse, Child, A Dependant may include the Spouse, Child,
Grandchild, Parent, Grandparent, Sibling or Grandchild, Parent, Grandparent, Sibling or
former Spouse of a HCV Infected Person to former Spouse of a HCV Infected Person to
whom that person was providing support or whom that person was providing support or
was under a legal obligation to provide was under a legal obligation to provide
support on the date of the HCV Infected support on the date of the HCV Infected
Person's death. Person's death.
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Applying for compensation
To receive compensation you must apply to the 1986-1990 Hepatitis C Claims
Centre using this Initial Claim Forms Package. The Forms along with the medical
documentation, information and test results requested, should provide the
necessary information to begin processing your Claim and to determine your
eligibility for compensation under the 1986-1990 Hepatitis C Class Action
The Administrator reserves the right to request clarification, more information or
to pursue further investigations, if necessary, to determine if you qualify for
compensation or to assess ongoing eligibility.
First claim deadline
No person may file a Claim for the first time under this Plan after 30 June 2010
a) The Claim is made within one year of the person attaining his or her age
of majority; or
b) The Claim is made within the three year period following the date upon
which the person first learned of his or her infection with HCV and the
Court having jurisdiction over the person grants leave to the person to
apply for compensation.
Different Initial Claim Forms Packages
There are different requirements, definitions and benefits provided for
Hemophiliacs and persons with Thalassemia Major and their families than for
other claimants infected with the Hepatitis C virus through Blood transfusions and
their families. Therefore, there are separate Initial Claim Forms Packages for
each of the two (2) groups. Hemophiliacs and persons with Thalassemia Major
and their families must apply under the Hemophiliac HCV Plan. Other persons
infected with the Hepatitis C virus through a Blood transfusion and their families
must apply under the Transfused HCV Plan.
The Forms to be completed are prefixed with abbreviations at the top right hand
corner of the Form. See chart below for a definition of the abbreviations.
Forms to be completed by Hemophiliacs (or persons with
HEMO Thalassemia Major) and their families.
Forms to be completed by other claimants who received
TRAN Blood transfusions and their families.
Forms to be completed by both Hemophiliacs (or persons
GEN with Thalassemia Major) and the Transfused claimants.
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The Initial Claim Forms Package for the Transfused HCV plan contains eight (8)
Forms. The Initial Claim Forms Package for the Hemophiliac HCV plan has six
(6) Forms. Each package has been designed to obtain the information necessary
to begin processing your Claim. All information you provide to the Administrator
will remain confidential.
The forms included in the Initial Claim Forms Package are as follows:
Initial Claim Forms Package
(The first series of Forms used to determine if claimant is an Approved Class Member)
If you are applying under the Transfused If you are applying under the Hemophiliac
HCV Plan (Schedule A of the Settlement HCV Plan (also Thalassemia Major)
Agreement) you must complete and return (Schedule B of the Settlement Agreement)
the following Forms: you must complete and return the following
1. TRAN 1 - General Claimant Information 1. HEMO 1 - General Claimant Information
Form - Transfused HCV Plan Form - Hemophiliac HCV Plan
2. TRAN 2 - Treating Physician Form 2. HEMO 2 - Treating Physician Form
3. TRAN 3 - Declaration Form by HCV 3. HEMO 3 - Declaration Form by HCV
Infected Person, HCV Personal Infected Person, HCV Personal Representative
Representative or Other Knowledgeable or Other Knowledgeable Person
4. TRAN 4 - Authorization to Initiate NO EQUIVALENT FORM
Traceback Procedure and/or to Release
5. TRAN 5 - Blood Transfusion History Form NO EQUIVALENT FORM
6. GEN 5 - Authorization for Release of 4. GEN 5 - Authorization for Release of
Information by HCV Infected Person or HCV Information by HCV Infected Person or HCV
Personal Representative Personal Representative
7. GEN 6 - Authorization for Release of 5. GEN 6 - Authorization for Release of
Information by HCV Infected Person or HCV Information by HCV Infected Person or HCV
Personal Representative – Québec Personal Representative – Québec
8. GEN 7 - Authorization to Release 6. GEN 7 - Authorization to Release
Compensation Plan / Program Information Compensation Plan / Program Information Form
We have made every effort to send you the specific Forms required for you to
make a Claim. However, should you discover that you received Forms that do
not correspond to your Plan, or if the Forms are not in your official language
preference, please call our help line at 1 877 434-0944 or by email at
email@example.com. At your request, we will immediately send you the correct
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The 1986-1990 Hepatitis C Settlement Agreement uses very specific language at
times. You may wish to become familiar with the various words and phrases of
the Settlement Agreement and its Schedules. To do this, please review the
definitions contained in the Definition section of the Initial Claim Forms package
for each Plan. Familiarizing yourself with the definitions will give you a better
understanding of the Settlement Agreement and its Schedules.
PLEASE SEE ANNEX A - Disease-Based Compensation Schedule for HCV-
The 1986-1990 Hepatitis C Settlement Agreement recognizes the progressive
nature of the damage caused by the Hepatitis C virus and provides a disease-
based compensation schedule (Level 1 to Level 6). If the disease level
progresses, Approved Class Members may apply to the Administrator to collect
the Fixed Payment, but not more frequently than every two (2) years unless the
Administrator is satisfied that there are exceptional circumstances that require a
more frequent re-assessment.
Types of compensation
The Transfused and the Hemophiliac HCV Plans provide for several types of
compensation to the HCV Infected Person and certain Family Members.
Depending on your personal circumstances, you may be eligible to receive one
or more of the following types of compensation:
1. Fixed Lump Sum Payments (based on the disease level)
2. Compensation for Out-of-Pocket Expenses
3. Compensation for Uninsured Treatment and Medication
4. Compensation for HCV Drug Therapy (levels 3 or higher only)
5. Compensation for Loss of Income
6. Compensation for Loss of Services in the Home
7. Compensation for Loss of Support (HCV Infected Person has died and the
death of the HCV Infected Person was caused by his or her infection with
8. Compensation for Uninsured Funeral Expenses (HCV Infected Person
must be deceased)
9. Compensation for certain Family Members (HCV Infected Person has died
and the death of the HCV Infected Person was caused by his or her
infection with HCV)
10. Compensation for Costs of Care (level 6 only)
The details of each payment type can be found in the enclosed orange
information brochure, in the Settlement Agreement or on the Web site. Should
you have any questions regarding compensation that is possibly available to you,
please contact the Claims Centre information help line at 1 877 434-0944 or visit
us at www.hepc8690.ca
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When completing the Forms, you will see that you need to provide us with
additional and supporting documentation. This additional documentation
includes, for example, copies of Blood test results, other medical and hospital
records, or reports or legal documentation establishing the claimant’s relationship
to the HCV Infected Person. Please make sure to send in copies of these
additional documents with your completed Forms package as they are required
to establish your eligibility.
Please note: We cannot assume responsibility for any lost or missing
documents. We urge you to keep copies of your Forms and all other
If you have difficulty obtaining any of the required documents, please call our
help line at 1 877 434-0944 or contact us by e-mail at firstname.lastname@example.org so that
we can assist you in obtaining them or advise you on alternative means of
fulfilling the requirements.
Medical costs related to applying for compensation
The Plans provide that only Approved HCV Infected Persons will be reimbursed
for medical expenses incurred in establishing a Claim.
We do not anticipate that you will need to seek legal representation in the Claim
process, but if you wish to do so, please feel free to call a lawyer of your choice
for assistance. If you do not have a lawyer and are having difficulty finding one,
you may call the Referral Line for your Provincial/Territorial Law Society.
The Administrator can serve you in both official languages. However, if you
speak a language other than English or French, and are uncomfortable with
completing these Forms, please seek the assistance of a person familiar with
your language who also understands either French or English.
How to contact the Administrator
You may contact the Administrator of the Hepatitis C Claims Centre:
• by e-mail, at email@example.com
• by regular mail, at :
PO Box 2370, Station D
Ottawa (Ontario) K1P 5W5
• by telephone: our toll-free number is 1 877 434-0944
• by fax: (613) 569-1763
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Before you contact us
We want to provide you with the best and most efficient service possible. You
can help us answer your questions more quickly and fully if you have all your
information ready. Before contacting us, please do the following:
Read the instructions in the Package;
Prepare all your questions and the details of your situation; and
Have readily at hand the application and/or Form you are attempting to
complete and any related documents, along with some paper and a pencil.
Alternative contact with the Administrator
If, for any reason, you require a person other than yourself to communicate with
the Administrator on your behalf, you must complete TRAN 1/HEMO 1 – Section
H – Contact Authorization to indicate your written consent to have this person
speak with us about your confidential file.
Your local telephone company provides a Relay Services Operator to assist in
placing or receiving calls from persons who use a TTY/Teletypewriter. Please
see the information section of your telephone directory to obtain further
information about this service.
We have included a set of preprinted bar-coded labels with these Forms. Please
place the label in the designated area on every Form that you submit. If it is
necessary to correct the preprinted name and/or address, please do so in the
space to the right of the label.
WE WILL NOT BE ABLE TO PROCESS YOUR CLAIM IN THE ABSENCE OF
THESE LABELS. If you do not receive the labels or have misplaced them,
please call 1 877 434-0944 for assistance.
Please be advised that the opt-out deadline has expired! If this Settlement
Agreement affects you, you can no longer opt out of it.
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Processing claims - Step by Step
Step 1: You must mail completed Initial Claim Forms and supporting documentation to the
Hepatitis C Claims Centre.
Step 2: The Hepatitis C Claims Centre will sort and scan your Claim Forms and supporting
documentation into the computer system.
Step 3: An Evaluator will review the Forms and supporting documentation. The initial review will
include an assessment of your claimant type and the disease level of the HCV Infected
Person. The Evaluator will determine if your submission is complete. In the event that
your submission is complete, the Evaluator will recommend that your Claim be
accepted or rejected.
Step 4: The Supervisor reviews the Claim for approval. If the Supervisor disagrees with the
recommendation to approve the Claim, inquiries with the Evaluator will be made to
clarify any uncertainty. If the Supervisor agrees, the Claim is approved.
Step 5: If the Claim is approved, a Full and Final Release, covered with a letter confirming the
compensation payment will be mailed to you.
In cases where the HCV Infected person died before January 1, 1999, supplemental
Forms (GEN 21/GEN 21M or HEMO 22/HEMO 22M) outlining the right to make an
election will be attached.
Step 6: You should carefully review, sign and date the Release in the presence of a witness.
You must return all pages of the original Release by mail to the Hepatitis C Claims
Step 7: Upon receipt of the original Release, the Hepatitis C Claims Centre reviews the Release
to ensure that you duly signed it.
Step 8: The Hepatitis C Claims Centre will make a request to the Federal, Provincial and
Territorial governments for funding equal to the total amount of approvals for the month.
Requests for funding are made on the 5 business day of every month. In light of this
fact, the Hepatitis C Claims Centre must receive the original signed Release no later
than the end of the 3 business day.
Step 9: Upon receipt of the funds from the Trustee, a cheque or direct deposit payment will be
made to you. Payments are made once a month, within the last ten (10) business days
of the month.
Step 10: The HCV Infected Person or the Estate and Family Members and/or Dependants in the
case where the HCV Infected Person has died, may claim supplementary
compensation on an ongoing basis for some or all of the following:
• $1,000.00 for every month of completed HCV Drug Therapy;
• Out-of-pocket expenses;
• Uninsured medical expenses;
• Loss of income or loss of services in the home due to the HCV infection;
• Loss of support for surviving Dependants if HCV materially contributed to the
death of the deceased HCV Infected Person;
• Costs of care (up to $50,000 per calendar year for level 6 approvals only.)
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Is your Claim complete?
An Initial Submission Checklist
Below, we have identified the Forms you need to fill out when presenting a Claim and
the steps you need to take for each one. Please review them thoroughly before
submitting your Claim.
TRAN 1 / HEMO 1 1. Complete all sections.
Form 2. Sign the Form, where indicated.
3. Attach a positive antibody/PCR test result.
1. Did the Physician sign the Form?
TRAN 2 / HEMO 2 2. Did the Physician select a disease level?
Form 3. Did the Physician complete Sections E, F, and G of the
4. Attach all medical documentation supporting the
selected disease level.
TRAN 3 / HEMO 3 1. Complete sections A, B, and C.
Form 2. Sign in front of a Commissioner of Oaths
IMPORTANT! Be sure to ask this individual to
confirm that he or she is a Commissioner of Oaths.
TRAN 4 Form 1. Sign the Form in the presence of a witness.
Please Note: All communication between the
Administrator and Canadian Blood Services (CBS) /
Héma-Québec is strictly confidential. If this Form is
unsigned, the Administrator cannot deal with CBS /
Héma-Québec on your behalf and this will delay
processing your Claim.
TRAN 5 Form 1. Complete all sections.
2. Attach all Blood transfusion records, even pre-1986
3. Attach all correspondence from Canadian Blood
Services or Héma-Québec.
GEN 5 Form (Optional but Recommended)
1. List all people or medical facilities that we may
If this Form is unsigned, the Administrator cannot speak
directly with Doctors, clinics or hospitals, if ever
necessary and this may delay processing your Claim.
GEN 6 Form (Optional but Recommended)
1. If this Form is unsigned, the Administrator cannot speak
(Québec only) directly with Doctors, clinics or hospitals or other facilities
in Québec, if ever necessary and this may delay
processing your Claim.
GEN 7 Form 1. Complete this Form if you have applied for and/or
received provincial compensation.
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