C-61.1, r. 19 - Regulation respecting the payment of indemnities to holders of hunting or trapping licences and the payment of third party damages

Schedule Disposition versions

2012-09-01

SCHEDULE A

(ss. 7 and 11)

FORM A

Ministère de la Justice

1200, route de l’Église

Québec, QC

HUNTING AND FISHING ACCIDENT

Name of licensee: Claim number:

Address: Age:

Licence No.: Hunting or Trapping

Occupation: Employer:

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Date:

Accident Place:

Time:

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Description of the accident: ____________________________________________________________________

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Name: Age:

__________________________________________

Injury or Address: Tel.:

damages to __________________________________________

a third Type of damage or injuries:

party __________________________________________

Employer: Occupation:

---

Name: Tel:

__________________________________________

Accident Address:

witness __________________________________________

Name: Tel:

__________________________________________

Address:

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Date: ________________________________________ Signed ________________________________________

N.B. This certificat must be completed in all cases of claim for indemnity.

CERTIFICATE FROM ATTENDING PHYSICIAN

(to be procured at the claimant’s expense)

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Name of patient

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Type of injuries

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Mention complications if any

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Did the victim suffer from a previous physical malformation?

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Name of the hospital where care are given

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Will there be total or permanent disability?

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I certify that this report is accurate to the best of my knowledge.

Signed at ______________________________ on this _______ day of ________________________ 20_______

_______________________________________________

(Physician’s signature)

In case of death, all claims must include:

(1) Death certificate;

(2) Receipts covering federal and provincial succession duties.

R.R.Q., 1981, c. C-61, r. 21, Sch. A; O.C. 1543-82, s. 4; O.C. 1289-84, s. 8.