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Hepatitis C - Class Actions Settlement
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1986-1990 Hepatitis C Settlement Agreement Forms

You can view the following forms in PDF format (you will need Acrobat Reader)

You may order the Initial Claim Form Package by sending an e-mail message to the Administrator (see "Ordering Forms") and these forms will be mailed to you if you meet the exceptions to the June 30, 2010 First Claim Deadline set out in the two Court Approved Protocols. 

All other Forms should NOT be printed and completed for purposes other than to review/practice completion of forms. Apart from the Initial Claim Form Package, you must be an Approved Class Member to receive forms. To ensure that your file is processed in a timely manner, please send in the ORIGINAL FORMS only. Forms downloaded from this Web site are NOT deemed to be ORIGINALS. Once your claim is approved, the Administrator will mail the necessary forms to you.

Initial Claim Form Package
(The first series of Forms used to determine if claimant is an Approved Class Member)
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Transfused HCV Plan (Schedule A) Hemophiliac HCV Plan (Schedule B)
General Instructions for completing the Initial Claims Forms General Instructions for completing the Initial Claims Forms
Instructions for completing the Initial Claims Forms Package Instructions for completing the Initial Claims Forms Package
TRAN 1 - General Claimant Information Form - Transfused HCV Plan HEMO 1 - General Claimant Information Form - Hemophiliac HCV Plan
TRAN 2 - Treating Physician Form HEMO 2 - Treating Physician Form
TRAN 3 - Declaration Form by HCV Infected Person, HCV Personal Representative or Other Knowledgeable Person HEMO 3 - Declaration Form by HCV Infected Person, HCV Personal Representative or Other Knowledgeable Person
TRAN 4 - Authorization to Initiate Traceback Procedure and/or to Release Information GEN 5 - Authorization for Release of Information by HCV Infected Person or HCV Personal Representative
TRAN 5 - Blood Transfusion History Form GEN 6 - Authorization for Release of Information by HCV Infected Person or HCV Personal Representative - Québec
GEN 5 - Authorization for Release of Information by HCV Infected Person or HCV Personal Representative GEN 7 - Authorization to Release Compensation Plan / Program Information Form
GEN 6 - Authorization for Release of Information by HCV Infected Person or HCV Personal Representative - Québec  
GEN 7 - Authorization to Release Compensation Plan / Program Information Form
Claims Where the HCV Infected Person Died Prior to January 1, 1999
(Compensation can be paid jointly to the Estate, Approved Family Members, and/or Dependants)
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Transfused HCV Plan (Schedule A) Hemophiliac HCV Plan (Schedule B)

GEN 21 - $120,000 Election for the Transfused HCV Plan or the Hemophiliac HCV Plan, Section 5.01 (2) - ADULT

Instructions for completing Form GEN 21

 HEMO 22 - $72,000 Fixed Payment for the Hemophiliac HCV Plan, Section 5.01 (4) - ADULTS

Instructions for completing Form HEMO 22

OR

OR

GEN 21M - $120,000 Election for the Transfused HCV Plan or the Hemophiliac HCV Plan, Section 5.01 (2) - MINOR AND MENTALLY INCOMPETENT PERSON

Instructions for completing Form GEN 21M

HEMO 22M - $72,000 Fixed Payment for the Hemophiliac HCV Plan, Section 5.01 (4) -  MINOR AND MENTALLY INCOMPETENT PERSON

Instructions for completing Form HEMO 22M

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Package comprising: Package comprising:
Out-of-pocket
(Only Approved Class Members will receive this Form)
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Transfused HCV (Schedule A) and Hemophiliac HCV (Schedule B) Plans

Instructions for completing Form GEN 3
GEN 3 AUT - Authorization for Release of Information by HCV Infected
Person or HCV Personal Representative
GEN 3 - Compensation for Uninsured Treatment/Medication and Out-of-Pocket Expenses
Costs of care
(Only approved Level 6 claimants will receive this form)
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Letter
GEN 4 AUT - Authorization for Release of Information by HCV Infected Person or HCV Personal Representative
GEN 4 - Compensation for Costs of Care
Election Forms
(Very specific instances where a payment election can be made)
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Transfused HCV Plan (Schedule A) Hemophiliac HCV Plan (Schedule B)
GEN 17 - Election for $30,000 Fixed Payment or Loss of Income/Services Payment Form

HEMO 23 - $50,000 Fixed Payment Under the Hemophiliac HCV Plan

Instructions for completing Form HEMO23

Other Risk Factors
(Inquiry Form)
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Transfused HCV (Schedule A) and Hemophiliac HCV (Schedule B) Plans

Letter and ORF Form

  

Loss of Income / Loss of Services in the Home / Loss of Support
(Only Approved Class Members will receive this package of Forms)
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Transfused HCV (Schedule A) and Hemophiliac HCV (Schedule B) Plans
GEN 10 Instructions
GEN 10 - Loss of Income/Support - Master Form
GEN 10A, 10B, 10C Instructions
GEN 10A - Supplemental Income/Information Form - Federal
GEN 10B - Supplemental Income/Information Form - Provincial
GEN 10C - Self-Employment Information Form
GEN 10 Renewal Instructions
GEN 10 Renewal Form - Loss of Income/Support
Undertaking Instructions
Undertaking Form - Loss of Services/Support
GEN 11 - Activities of Employment
GEN 12 - Loss of Services in the Home- Master Form
GEN 19 - Authorization to Release Employee's Information Form
Indexation Table
Request for Review
Transfused HCV (Schedule A) and Hemophiliac HCV (Schedule B) Plans
Instructions for completing Request for Review Form
Request for Review Form
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