Fillable Printable Application for Disability Benefits - Quebec
Fillable Printable Application for Disability Benefits - Quebec
Application for Disability Benefits - Quebec
Application for Disability Benefits
Information
Disability benefits
If you are under age 65, have sufficiently contributed to the
Québec Pension Plan and are disabled, you could be entitled
to disability benefits under the Plan. There are two pensions:
the disability pension;
the pension for a disabled person’s child.
The Régie des rentes du Québec can deem you to be disabled
if your disability is severe and if it prevents you from doing any
type of work on a full-time basis. In addition, your disability
must be permanent, which means it is of indefinite duration
with no possibility of improvement.
However, if you are between ages 60 and 65 and your state
of health prevents you from doing the usual work you left when
you became disabled, you could be entitled to a disability
pension. You will have to prove that you recently worked,
that is, that you contributed to the Plan for at least four of
the last six years in your contributory period. The contributory
period ends in the year in which the Régie deems a person
to be disabled.
If you are under 65 years of age, a beneficiary of a
retirement pension under the Québec Pension Plan and
we can no longer cancel your retirement pension, you could
receive an additional amount for disability if you are unable to
do any type of work on a full-time basis. Note that you must
show that you recently worked.
Important: You must notify the Régie if you return to
work while your application for disability benefits is being
studied.
Disability pension or additional amount
for disability
A disability pension or an additional amount for disability is:
payable as of the fourth month following the one in
which the Régie considers a person to be disabled.
Thus, a person who is deemed to be disabled as
of January receives a first pension payment in May.
The last payment is made in the month of the person’s
65th birthday. The disability pension is automatically
replaced by a retirement pension at that time;
increased each year in January, according to the cost
of living;
subject to income tax.
Pension for a disabled person’s child
If you are granted a disability pension, your children could
be entitled to a pension for a disabled person’s child until
age18, if an application is filed.
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They are eligible for the
pension if they:
are your biological or adopted children; or
have been living with you for at least one year and you
serve as mother or father to them.
Children are not eligible for this pension if they were
placed in your home in foster care and you are receiving
amounts for them.
The pension for a disabled person’s child is paid on a
priority basis to the disabled person who provides for the
children’s needs. Otherwise, the pension is paid to the person
responsible for the children. Regardless of who is receiving
the pension for a disabled person’s child, it does not reduce
the amount of the disability pension.
The pension for a disabled person’s child is paid monthly.
Payment ends when the child turns 18 or the disability pension
stops being paid. The person receiving the pension must notify
the Régie if he or she is no longer responsible for the children.
Impact on other benefits
If you are already receiving a surviving spouse’s pension under
the Québec Pension Plan, that pension could be reduced
once a disability pension becomes payable. Please note that
you cannot receive disability benefits under the Plan if you
are already receiving disability benefits under the Canada
Pension Plan.
The Régie’s criteria for determining if a person is disabled
are not the same as those of the Commission de la santé et
de la sécurité du travail (CSST), the Société de l’assurance
automobile du Québec (SAAQ) or the Ministère de l’Emploi
et de la Solidarité sociale. The criteria used by insurance
companies may also differ from those of the Régie.
If you receive or expect to receive benefits from other public or
private sources, you should find out from those other sources
whether or not receiving disability benefits under the Québec
Pension Plan would cause such benefits to be reduced.
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Children for whom an orphan’s pension or a pension for a disabled person’s
child is already being paid under the Québec Pension Plan or the Canada
Pension Plan are not entitled to a second pension.
A pension for a disabled person’s child is not payable where a beneficiary
of a retirement pension is receiving an additional amount for disability.
Continued on other side
B-071-1A (14-01)
How to apply
Fill out the form and return it to the Régie immediately. Do not
wait for the Medical Report. The date the Régie receives
your application may affect the date you begin receiving
your benefits, since the maximum retroactivity possible
is 12months from the date we receive the application, even
if you were disabled before that time.
You must have the Medical Report completed by your
physician. Be sure to ask him or her to send it back to the
Régie as soon as possible. Your physician may charge you
a fee for filling out the Medical Report. You are responsible
for paying that fee.
Work outside Canada
If you participated in a social security plan in another country,
you could be entitled to a pension under that plan. Benefits
paid under the Québec Pension Plan are not reduced if you
are receiving a pension from another country.
Instructions – Application for Disability
Benefits
1. Answer all the questions on the Application for Disability
Benefits and sign it.
2. Fill out and sign the Consent Regarding the Release
of Medical, Psychosocial and Administrative
Information.
3. Include a copy of all medical reports and test results that
you have in your possession that concern your disability.
(Do not send X-ray films.)
4. Be sure to use sufficient postage, and mail it to the
following address as soon as possible:
Régie des rentes du Québec, Case postale 5200
Québec (Québec) G1K 7S9
Instructions – Medical Report form
1. You (the applicant) must fill out section 1 of the Medical
Report, Information about the applicant’s identity.
2. Have the other sections completed by your physician.
He or she will send the report directly to the Régie.
Access to documents held by public bodies
and the protection of personal information
The information requested on this form is needed in order
for the Régie to study your application. Failure to provide the
information may result in delays in processing the application
or in the application being rejected. Only authorized
employees at the Régie will have access to the information.
The information can be provided to other persons or agencies
or verified with them only in the cases provided for by law. It
could also be used for research, assessments, enquiries or
surveys. Under the Act respecting Access to documents held
by public bodies and the Protection of personal information,
you may consult the information and have your personal
information corrected.
Time required to render a decision
In our Service Statement, we are committed to replying to
an application for disability benefits within a maximum of
150days, if the information received initially is sufficient to render
a decision. However, three times out of four, applicants did not
have to wait more than 82days (results obtained between
November2012 and October2013). The time period begins
once we have received your application and the Medical Report.
In addition, to check the status of your application, consult the
My Account online service at any time.
Main steps in processing your application
When processing your application for disability benefits, the
Régie will carry out the following steps:
When your application is received, it will be studied.
Your application will be checked against administrative
criteria in order to determine your eligibility for benefits
under the Québec Pension Plan (the number of years
you contributed to the Plan, the date you stopped
working, etc.). Any missing information will be obtained,
as required.
If you are eligible from an administrative standpoint, your
application moves on to the next steps:
Your file will be sent to the Régie’s medical advisors.
The medical information in your application and the
Medical Report will be verified. In order to complete
your medical file, additional medical information may
be obtained, as required, from your attending physician,
medical specialists, hospitals, insurance companies
or government agencies with which you have been
in contact.
A medical advisor at the Régie will review your medical
file to determine whether you can be deemed to be
disabled under the Act respecting the Québec Pension
Plan. Under certain circumstances, you may be asked
to undergo a medical examination.
The Régie will render a decision with regard to your
application.
For more information
Online
By telephone
Québec region: 418 643-5185
Montréal region: 514 873-2433
Toll-free: 1 800 463-5185
B-071-1A (14-01)
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area codearea code
year month day
Application for Disability Benefits
1. Identification
Indicate your social insurance number
2. Participation in other plans
Régie des rentes du Québec B-071A (14-01)
0100002 LE
Sex Family name Given name
Family name at birth, if different Given name at birth, if different
Date of birth Place of birth (
city, province, country)
Your mother’s family name at birth Your mother’s given name
Your father’s family name Your father’s given name
Language of correspondence French English
Your address (number, street, apt.)
City Province Country Postal code
Telephone
Home Other Extension
If you live outside Canada, what was your last province of residence in Canada?
Please print
Have you ever participated in the social security plan of another country? Yes No
If so, in which country or countries?
Please indicate your foreign social insurance numbers.
Important: You must provide your social insurance number where requested to avoid delays in processing your application.
If you need more space, use a separate sheet. Be sure to indicate your social insurance number on it and indicate the number
of the question to which the information pertains.
Please complete the form and return it to:
Régie des rentes du Québec, Case postale 5200, Québec (Québec) G1K 7S9
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Child born
outside
Canada
Child born
outside
Canada
Child born
outside
Canada
Child born
outside
Canada
year month day
year month day
year month day
year month day
year month
year month
year month
year month
year month
year month
year month
year month
year month
year month
year month
year month
3. Information about your children
Régie des rentes du Québec B-071A (14-01)
3.1 Did you have children or become responsible for any children?
Yes No. Go to section 4.
3.2 Did you receive family benefits paid in your name for any children OR, if you did not, was it because your family income was
too high? (Benefits are usually paid to the mother.)
Yes. Complete the following. No. Go to section 4.
Information about your children
1st child
Family name at birth Given name Date of birth
Place of birth (province, country)
Date of adoption or date child became
Date of death (if child died before age 7)
(i
your dependent
f applicable)
Date of arrival in Canada Province of residence at time of arrival in Canada
2nd child
Family name at birth Given name Date of birth
Place of birth (province, country)
Date of adoption or date child became
Date of death (if child died before age 7)
(i
your dependent
f applicable)
Date of arrival in Canada Province of residence at time of arrival in Canada
3rd child
Family name at birth Given name Date of birth
Place of birth (province, country)
Date of adoption or date child became
Date of death (if child died before age 7)
your dependent
(if applicable)
Date of arrival in Canada Province of residence at time of arrival in Canada
4th child
Family name at birth Given name Date of birth
Place of birth (province, country)
Date of adoption or date child became
Date of death (if child died before age 7)
y
(if
our dependent
applicable)
Date of arrival in Canada Province of residence at time of arrival in Canada
If there are more than four children, provide the additional information on a separate sheet.
3.3 Between the birth and the 7th birthday of each of these children, were there any periods during which family benefits were
not paid in your name? Yes No
3.4 Between each child’s birth or arrival in Canada and that child’s 7th birthday, did each of these children always live with
you in Canada? Yes No
Certain situations could help you become eligible for benefits or increase the amount:
if you received family benefits for any children (Québec child assistance, Québec family allowance or Canada Child Tax Benefit);
if you were entitled to family benefits but did not receive any because your family income was too high.
Indicate your social insurance number
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4. Benefits from other agencies
5. Education and training
Régie des rentes du Québec B-071A (14-01)
Indicate your social insurance number
4.1 Have you ever applied for an indemnity from the Commission de la santé et de la sécurité du travail (CSST) following a work-
related accident or an occupational disease (whether or not it was related to your current disability)? Yes No
If so, in what year? Give your CSST file number.
For what reason?
What is the current status of your file at the CSST?
I have not yet received an answer from the CSST.
I am currently receiving an indemnity from the CSST.
I was receiving an indemnity from the CSST but have stopped receiving it.
The CSST rejected my application.
Did the CSST ask for an expert medical opinion?
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Yes No
4.2 Have you ever applied for an indemnity from the Société de l’assurance automobile du Québec (SAAQ) following an automobile
accident (whether or not it was related to your current disability)? Yes No
If so, in
what year did the accident occur?
Give your SAAQ file number.
What is the current status of your file at the SAAQ?
I have not yet received an answer from the SAAQ.
I am currently receiving an indemnity from the SAAQ.
I have received an indemnity from the SAAQ in the last 12 months but have stopped receiving it.
I was receiving an indemnity from the SAAQ but stopped receiving it more than 12 months ago.
The SAAQ is currently reviewing my application.
The SAAQ rejected my application.
Did the SAAQ ask for an expert medical opinion?
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Yes No
4.3 Have you ever applied for benefits from an insurance company because of your disability? Yes No
If so, indicate the company’s name. Give your file number.
Did the insurance company ask for an expert medical opinion?
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Yes No
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By “expert medical opinion,” we mean an appointment with a physician or a health care professional at the request of a third party (e.g. CSST, SAAQ, insurance
company, employer or other). Unlike the attending physician, the physician or health care professional does not treat the person he or she is asked to examine.
5.1 What level of education did you complete? Elementary Secondary
College University
What is the last diploma you received?
5.2 Please list any other training and development (including workplace training, special interest classes, etc.).
5.3 Do you have a driver’s license in good standing? Yes No
If so, indicate the class or classes:
If there are any restrictions indicated on your license, please list them.
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6. Work situation
7. Work history
Régie des rentes du Québec B-071A (14-01)
6.1 Date you started your current job or your last job
year month day
6.2 Have you completely stopped working? Yes No
If so, what is the date of the last day you went to work?
year month day
If not, how many hours a week do you work?
Hours
What is your gross weekly salary?
$
Note: If you return to work or your work hours increase before the Régie has finished studying your application for disability benefits,
please notify us.
6.3 Why did you totally or partially stop working?
6.4 What is or was your job?
Briefly describe your work.
Name of your last employer:
Telephone
area code
Extension
6.5 Do you have another job? Yes No
If so, how many hours a week do you work?
Hours
What is your gross weekly salary? $
Employer’s name:
Telephone E
area code
xtension
6.6 Are you currently self-employed? Yes No
6.7 Do you own a business? Yes No
If so, indicate its name:
Are you still involved in any way in the business’s activities? Yes No
If so, what are your duties?
6.8 Have you ever been self-employed or owned a business? Yes No
If so, please give the date the business was sold, dissolved or closed.
year month day
6.9 Have you ever been or are you responsible for a family-type or intermediate resource (foster home or family)?
Yes No
If so, did or do you take in nine or fewer users at your principal place of residence? Yes No
List the other jobs you held before the job described in section 6.
Employer Type of work
Duration
Reason for leaving
year month year month
year month year month
year month year month
If there is not enough space, provide the additional information on a separate sheet.
From To
Indicate your social insurance number
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8. Information on your state of health
Régie des rentes du Québec B-071A (14-01)
Indicate your social insurance number
8.1 Since when have you been unable to work on a regular basis because of your state of health?
year month day
8.2 List the illnesses or impairments that prevent you from working or limit you in your work. If you do not know the exact medical
terms, describe the problem in your own words.
8.3 List all the medications that you are currently taking.
Name of the medication The dose you take How often you take it
8.4 Indicate any other treatment (physiotherapy, psychotherapy, etc.) that you are currently receiving and the place where
you are treated.
Treatment Place
8.5 Indicate, if possible, any special tests you have had during the past six months that are related to the health problem
causing your disability (x-rays, treadmill exercise, magnetic resonance imaging, respiratory test, etc.).
Type of test Hospital or clinic where the test was done
8.6 Can you get around without aid? Yes No
If you answered no, which of the following do you use?
Cane Crutches Wheelchair Other:
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year month
year month
year month
area code
area code
area code
year month day
year month day
year month day
9. Information about your physicians
10. Information on hospital stays
Régie des rentes du Québec B-071A (14-01)
Name the physicians currently caring for you and any physicians you have seen because of your disability. Also indicate the type
and name of the institution at which you consulted the physician.
1st physician
Physician’s name Telephone
Family physician
Specialist
In the case of a specialist, please indicate in which field.
Type of establishment Name of establishment Date you last saw that physician
Hospital CLSC Clinic
2nd physician
Physician’s name Telephone
Family physician
Specialist
In the case of a specialist, please indicate in which field.
Type of establishment Name of establishment Date you last saw that physician
Hospital CLSC Clinic
3rd physician
Physician’s name Telephone
Family physician
Specialist
In the case of a specialist, please indicate in which field.
Type of establishment Name of establishment Date you last saw that physician
Hospital CLSC Clinic
If there is not enough space, provide the additional information on a separate sheet.
Have you been hospitalized in the last five years? Yes. Give the following information. No
1st hospitalization
Approximate date Reason
Name of the hospital Location
2nd hospitalization
Approximate date Reason
Name of the hospital Location
3rd hospitalization
Approximate date Reason
Name of the hospital Location
Indicate your social insurance number
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Régie des rentes du Québec B-071A (14-01)
year month day
year month day
11. Application for a pension for a disabled person’s child
Indicate your social insurance number
For information on the eligibility requirements, refer to the accompanying information sheet.
11.1 Complete the following for each child for whom you wish to apply for a pension for a disabled person’s child. Be sure to
indicate the child’s social insurance number, if any.
11. 2 Is an orphan’s pension or a pension for a disabled person’s child being paid under the Québec Pension Plan or the Canada
Pension Plan for any of the children named above? Yes No
If so, please indicate under which social insurance number.
11. 3 If the children are yours, but do not live with you, indicate the amounts that you provide each month for their needs (support
payments, if any, school fees, medical or dental expenses, clothing, school supplies, etc.).
$ a month
1st child
Sex Family name at birth Given name Social insurance number
Date of birth Place of birth (city, province, country)
His or her mother’s given and family names at birth His or her father’s given and family names
Child’s address
Same as the disabled person’s address
Other address:
Is this child your biological or adopted child? Yes No
If so, for an adopted child, indicate the date of adoption.
year month day
If not, please indicate when the child began living with you, if applicable.
year month day
If the child does not live with you, please specify the reason.
2nd child
Sex Family name at birth Given name Social insurance number
Date of birth Place of birth (city, province, country)
His or her mother’s given and family names at birth His or her father’s given and family names
Child’s address
Same as the disabled person’s address
Other address:
Is this child your biological or adopted child? Yes No
If so, for an adopted child, indicate the date of adoption.
year month day
If not, please indicate when the child began living with you, if applicable.
year month day
If the child does not live with you, please specify the reason.
If there is not enough space, provide the additional information on a separate sheet.
If the child was born outside Québec,
p
o
rovide proof of birth issued by an officer
f civil status from his or her place of birth.
If the child was born outside Québec,
p
o
rovide proof of birth issued by an officer
f civil status from his or her place of birth.
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year month day
area code area code
year month day
13. Declaration and signature
12. Payment by direct deposit
Please provide your banking information to sign up for direct deposit. Your benefits will be paid directly into your bank account
at a financial institution in Canada.
The account provided must be in your name or that of the beneficiary if you are applying on his or her behalf.
If you already receive a pension from the Régie by direct deposit, your benefits will be deposited in the same bank account.
If so, you do not need to fill out this section.
Name of your financial institution
Address of your financial institution
Branch number
(transit)
Bank or caisse
number
Account number
(folio)
Régie des rentes du Québec B-071A (14-01)
I declare that all information given on this application is true and correct.
I agree to inform the Régie des rentes du Québec if there is any change in my work situation or my state of health between now
and the time a decision is rendered.
Signature Date
If you completed and signed the form for the person applying for the benefits, please provide the following information.
Why was the person unable to complete and sign the application?
Are you related to the applicant?
No Yes
. If so, how?
In what capacity did you sign (guardian, mandatary, etc.)?
Sex Family name Given name
Address (number, street, apt.)
City Province Country Postal code
Telephone
Home Other Extension
If you are an individual, you must also provide the following information:
Your social insurance number
Your date of birth Your mother’s family name at birth
In order to avoid delays in processing your application, be sure you have:
duly completed all sections of the form;
provided your social insurance number where indicated;
signed this form;
completed and signed the enclosed Consent Regarding the Release of Medical, Psychosocial and Administrative
Information form.
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Indicate your social insurance number
0100009 LA
Régie des rentes du Québec B-077A (13-04)
Consent Regarding the Release of Medical, Psychosocial and Administrative
Information
1. Identifi cation
2. Consent and signature
Indicate your social insurance number
Indicate your health insurance number
Sex Family name Given name Date of birth
Family name at birth, if different
Given name at birth, if different
Your mother’s family name at birth Her given name
Your father’s family name His given name
Please print
I am providing consent authorizing any physician, health professional, health care facility or social services institution to release
to the Régie des rentes du Québec any pertinent medical, psychosocial or administrative information concerning me so that the
Régie will have all the information needed to process my application for disability benefi ts.
This consent is also given with respect to my employers, the Commission de la santé et de la sécurité du travail, the Société
de l’assurance automobile du Québec, the Secrétariat du Conseil du trésor, the Secrétariat de la santé et des services sociaux,
the Services conseils aux gestionnaires des réseaux de l’éducation, the Commission administrative des régimes de retraite et
d’assurances as well as any administrator of an insurance plan to which I have applied for benefi ts related to my state of health.
Unless revoked by me in writing, this consent shall be in effect, even in the event of my death, until a final decision is
rendered by the Régie. The consent covers all the medical, psychosocial and administrative information held before the date
of the consent and any obtained between the date of the consent and the date of the fi nal decision.
Signature Date
year month day
Note:
The original consent remains on fi le at the Régie. A certifi ed true copy
of the original shall be considered to be authentic, pursuant to section
25 of the Act respecting the Québec Pension Plan.
year month day
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