Are you encountering obstacles with CSST, the SAAQ, the QPP, or your insurance company?
Click on the appropriate organization:
CSST
SAAQ
QPP
INSURANCE
Is your situation a result of a work accident?
Or an illness related to your profession?
When did the work injury occur? Exceeded maximum number of characters.
What is your date of birth? Exceeded maximum number of characters.
Has a decision pertaining to your case been made? yes no Select an answer
if Yes, by whom? Select from the following choices The CSST The Administrative Review Dept. la commission des lésions professionnell
Date : Exceeded maximum number of characters.
What was the decision :
Eligibility denied
Advice from the Medical Review Board (Bureau d'évaluation médicale)
Percentage of physical or mental impairment
Return to the same job held before the work injury occurred
Find equivalent or suitable employment
Ability to perform the job that has been deemed equivalent or suitable
Complaint under section 32 of the Act
Other (explain in ten words or less)
Exceeded maximum number of characters.
CSST-Did you contest the decision ? yes no Select an answer
If yes, on what date? Exceeded maximum number of characters.
How much are you prepared to invest in your case?
$0.00
$1.00 - $1,000
$1,001 - $3,000
$ 3,001 +
Before submitting your form, for security purposes please enter the characters shown in the box below:
Date of the accident: Exceeded maximum number of characters.
Status:
Salaried employee
Student
Disabled (for a reason other than the road accident)
Self-employed
Retired
Has your case been decided? yes no Select an answer
if Yes, by whom? Select from the following choices The SAAQ The Review Board The Administrative Tribunal of Quebec
What was the decision:
Deemed employment (determining an employment)
Cessation of the Income Replacement Indemnity
Assessment of the sequelae
Reimbursement of costs
Personal assistance
Rehabilitation
Care expenses
SAAQ-Did you contest the decision? yes no Select an answer
What is your date of birth: Exceeded maximum number of characters.
Date on which disability began: Exceeded maximum number of characters.
Scope of the disability:
Unable to perform any substantially gainful occupation
Unable to perform your former gainful occupation due to the disability
if Yes, by whom? Select from the following choices The Quebec Pension Board The QPP Review Board The Administrative Tribunal of Quebec
no disability found
full income indemnity awarded by the CSST
insufficient contributions to the plan
Did you contest the decision? yes no Select an answer
Type of insurance
Name of the insurer: Exceeded maximum number of characters.
Did you receive payment from the insurer? yes no Select an answer
If so, what type of payment?
When did the disability begin? Exceeded maximum number of characters.
Please describe the disability in ten words or less. Provide your doctor's diagnosis.
When did the insurer begin payment? Exceeded maximum number of characters.
When did the insurer cease payment? Exceeded maximum number of characters.
Date on the insurance company's letter notifying you that it will not pay Exceeded maximum number of characters.
Grounds for refusal:
compensation being paid by another plan (CSST, SAAQ, RRQ, other governmental plan, other insurance company)
policy is invalid (contains false statements, etc.)
other (explain in ten words or less)
Did you request compensation for this disability from a party other than your insurer? yes no Select an answer
If so, to whom did you make the request?
CSST SAAQ QPP another personal or group insurer criminal victims compensation employment insurance income security other
Did you file a suit against your insurer? yes no Select an aswer
If so, provide the court case number: Exceeded maximum number of characters.
