CSST, SAAQ, QPP or insurance cases?

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CSST

SAAQ

QPP

INSURANCE

CONTACT INFORMATION:  
 Name:   A value is required.Exceeded maximum number of characters.Minimum number of characters not met.
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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?

if Yes, by whom?

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)

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CSST-Did you contest the decision ?

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 +

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 CONTACT INFORMATION:  
 Name:   Exceeded maximum number of characters.A value is required.Minimum number of characters not met.
 Address:   Exceeded maximum number of characters.
 City:   Exceeded maximum number of characters.
 Province / State:   Exceeded maximum number of characters.
 E-mail:   A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
 Telephone number:   A value is required.Minimum number of characters not met.Exceeded maximum number of characters.
 Fax number:   Exceeded maximum number of characters.

Date of the accident: Exceeded maximum number of characters.

What is your date of birth? 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?

if Yes, by whom?

Date : Exceeded maximum number of characters.

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

Other (explain in ten words or less)

Exceeded maximum number of characters.

SAAQ-Did you contest the decision?

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 +

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 CONTACT INFORMATION:  
 Name:   Exceeded maximum number of characters.Minimum number of characters not met.A value is required.
 Address:   Exceeded maximum number of characters.
 City:   Exceeded maximum number of characters.
 Province / State:   Exceeded maximum number of characters.
 E-mail:   A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
 Telephone number:   A value is required.Minimum number of characters not met.Exceeded maximum number of characters.
 Fax number:   Exceeded maximum number of characters.

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

Has your case been decided?

if Yes, by whom?

Date : Exceeded maximum number of characters.

What was the decision:

no disability found

full income indemnity awarded by the CSST

insufficient contributions to the plan

Did you contest the decision?

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 +

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 CONTACT INFORMATION:  
 Name:   Exceeded maximum number of characters.Minimum number of characters not met.A value is required.
 Address:   Exceeded maximum number of characters.
 City:   Exceeded maximum number of characters.
 Province / State:   Exceeded maximum number of characters.
 E-mail:   A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
 Telephone number:   Minimum number of characters not met.Exceeded maximum number of characters.A value is required.
 Fax number:   Exceeded maximum number of characters.

Type of insurance

Personal Salary
Group Mortgage
Don't know Don't know

Name of the insurer: Exceeded maximum number of characters.

Did you receive payment from the insurer?

If so, what type of payment?

short term
  long term

When did the disability begin? Exceeded maximum number of characters.

Please describe the disability in ten words or less. Provide your doctor's diagnosis.

Exceeded maximum number of characters.

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:

no disability found

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)

Exceeded maximum number of characters.

Did you request compensation for this disability from a party other than your insurer?

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

Exceeded maximum number of characters.

Did you file a suit against your insurer?

If so, provide the court case number: 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:

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