1. The Claims Administrator, Velvet Payments Inc., must receive this form duly completed and signed by no later than 5:00 p.m. EASTERN on January 3rd, 2021.
  2. Please make sure to complete one form per claimant. Each person residing at the same address during the admissible period must complete their own form (i.e. Each member must complete an individual claim form to receive the payment of an indemnity).
  3. A claimant who was a minor during the periods covered by the class action settlement may establish their residence by proving the residence of their parents.
  4. A list of addresses within the perimeter eligible for compensation under the class action settlement is attached below. Please consult this list before completing the form or sending it to the Claims Administrator. If you did not live at one of the addresses listed from 2016 to 2017, please do not complete the form, as you are not eligible for compensation and your claim will be refused.
  5. The amount of compensation you will receive depends on where you resided in 2016 and/or 2017 and will also depend on the number of people who will submit a valid claim.
  6. To qualify for compensation, you will also have to provide the Claims Administrator with your proof of residence in 2016 and/or 2017. You may provide one of the following documents as a proof of residence for each year: lease of a dwelling, Hydro-Quebec bills, invoices for telephone or Internet services, Notice of assessment from the tax authority, correspondence from a government agency or a letter from the Chief Electoral Officer of Quebec confirming the place of residence. You can submit these documents by uploading them on the Claim Form or by sending them via email to (pictures and scans are acceptable).
  7. If you do not include proof of residence with your claim and the Claims Administrator is unable to obtain confirmation of your address, your claim will be denied and you could then address your contestation, if any, to the Superior Court of Quebec, District of Montreal.
  8. You must declare in the Claim Form that the information provided therein is true and accurate, under penalty of perjury.
  9. For more information, you can consult the Settlement and the documentation on the websites of the Claims Administrator ( or the class counsel (
  10. If you require assistance in completing the Claim Form, please contact Amanda Brook at (514) 488-0236.
  11. Please note that if your claim is accepted by the Claims Administrator, you will not receive a notice informing you of this acceptance and your compensation will be forwarded to you via email Interac e-transfer. You must have a bank account that can accept Interac e- transfers to collect any compensation. Compensation can only be collected for a period of thirty (30) days after the Interac e-Transfer is sent to the e-mail address you provide. If you are unable to accept e-transfers, please inform the Claims Administrator by email as soon as possible.
  12. You must notify the Claims Administrator of any changes of your email address or mailing address until you receive your compensation.

    1. List of addresses within the perimeter eligible for compensation
      901 Girouard Avenue
      903 Girouard Avenue
      905 Girouard Avenue
      907 Girouard Avenue
      911 Girouard Avenue
      913 Girouard Avenue
      915 Girouard Avenue
      917 Girouard Avenue
      919 Girouard Avenue
      921 Girouard Avenue
      923 Girouard Avenue
      5451 Saint-Jacques Street
      5453 Saint-Jacques Street
      5457 Saint-Jacques Street
      5459 Saint-Jacques Street
      5463 Saint-Jacques Street
      5465 Saint-Jacques Street
      5469 Saint-Jacques Street
      5471 Saint-Jacques Street
      5473 Saint-Jacques Street
      5475 Saint-Jacques Street
      5477 Saint-Jacques Street
      5479 Saint-Jacques Street
      5481 Saint-Jacques Street
      5483 Saint-Jacques Street
      5485 Saint-Jacques Street
      5487 Saint-Jacques Street
      5489 Saint-Jacques Street
      5491 Saint-Jacques Street
      5493 Saint-Jacques Street
      906 Addington Street
      926 Addington Street
      928 Addington Street
      932 Addington Street
      934 Addington Street
      934A Addington Street
      938 Addington Street
      940 Addington Street
      942 Addington Street
      944 Addington Street
      950 Addington Street
      952 Addington Street
      958 Addington Street
      960 Addington Street
      964 Addington Street
      966 Addington Street
      970 Addington Street
      972 Addington Street

      To seek compensation in the above-described class action Settlement, please provide the following information and the required proof of residence. Any compensation that is provided in response to your claim will be sent via Interac e-Transfer to the e-mail address you provide. For assistance in completing this form, please contact Amanda Brook at (514) 488-0236.

      Part 1 - Identification of the Claimant


      Date of Birth*
      Unlike your Social Insurance Number, your Health Insurance Number consists of four letters followed by eight digits. Example: ABCD 1234 5678
      Your compensation will be sent to you via Interac e-transfer to this email address. Reminder: you must notify the Claims Administrator of any change of email or postal address until you receive your compensation.
      This security question will be asked via the Interac e-transfer when you receive compensation (if applicable). You must remember your answer to be able to accept the e-transfer.

      Part 2 - Proof of residence

      If you were a minor up until December 31, 2017 and lived with your parents, it is important to give their full names. You can prove your residence by proving the residence of your parents. Additional documents may be requested by the administrator.

      Start date
      End date
      Add another address +
      The documents provided as proof of residence must contain your name (or the name of your parents), a date and your address(es). You may upload a picture or scanned document. You may also send these documents to the Claims Administrator by email ( You may submit a claim without a proof of residence. However, if you do not attach a proof of residence to your claim (or do not send it via email) and the Claims Administrator cannot obtain confirmation of your address(es), your claim will be refused.

      Part 3 - Authorization

      I waive the confidentiality of the information regarding my place of residence for the benefit of the Claims Administrator for purposes of assessing the eligibility of my claim under the Settlement, the class counsel and the defendant's attorneys.

      I authorize the Directeur général des élections du Québec to provide these persons with my address of residence on the electoral lists produced during the provincial general elections of April 7, 2014, and of October 1, 2018:

      I also authorize the Régie de l'assurance maladie du Québec to provide these persons with, or confirm, my home address for the period of January 1, 2016 to December 31, 2017:


      Part 4 - Solemn Declaration and Signature

      By signing and dating this form below, I solemnly declare that the information provided is true to the best of my knowledge. I make this declaration believing it to be true and knowing that it is of the same force and effect in law as if made under oath. A person who makes a false statement under oath with the intent to deceive commits perjury and is liable to criminal charges under section 131 of the Criminal Code.

      Date: 2020-12-02

      If you have any questions while completing the Claim Form, please contact Amanda Brook at (514) 488-0236.