Forms and Guides

Éditeur de contenu

Important: Before filling out a form, download it to your workstation by right clicking the form’s download link and selecting “Save link as”.

Forms cannot be filled out from your browser or on a tablet or smartphone.

Fill out the forms and send them:

via our electronic document transmission service
by fax
by mail to IVAC

Qualification application

Qualification application are used to apply for financial assistance or an established support measure.

Persons who are victims or rescuers

Apply for qualification online

Use our online service How to submit an application for qualification to IVAC.

Note :

If you are unable to use the online services, you can use the:

Consult the guide that applies to your situation to help you complete your application.:

Selection of benefits

Clientele:Persons who are victims of a criminal offence committed by use of a motor vehicle

Complete this form to let us know which benefit plan you have selected.

Download the form Selection of Benefits (PDF | 638 KB)

Designation of a significant person

Important : To receive the financial assistance provided for in the Act to assist persons who are victims of criminal offences and to facilitate their recovery, the significant person must complete the Application for qualification form and have the Designation of a significant person form below completed by the victim or by their representative if the victim is a minor or incapable.

A person who has been injured and who wants to allow one or more significant persons to obtain psychotherapeutic or psychosocial assistance must designate them by filling out a form for each person.

A maximum of 30 sessions can be allocated for all the significant persons designated for the same event.

Please specify the number of sessions you would like to allocate for each designated person.

Download the form Designation of a significant person (PDF | 147 KB)

Medical forms and forms for professional services providers

All medical and psychotherapeutic or psychosocial intervention forms are available in French only.

These forms can be filled out directly on your computer and sent through our electronic service.

Other forms

Complete the dynamic forms and send them:

via our electronic document transmission service
by fax
by mail to IVAC

Modality choice for lump sum payment

Fill out this form to choose the terms of the lump sum payment.

Download the form Authorization to send a copy of the file (PDF | 239 KB)

Claims for reimbursement

Person who is a victim or rescuer

Travel expenses, medications, meals and accommodations, other

An automated payment service for prescription drug costs is now available in Québec pharmacies. You can therefore procure drugs prescribed for the treatment of your injury without disbursing anything, by mentioning that you receive benefits from IVAC and by presenting your Health Insurance Card.

For drugs for which reimbursement is not authorized directly at the pharmacy, even if they were prescribed in relation to treatment of your injury, you may submit a claim for reimbursement of these costs to IVAC, attaching the receipt for the drugs to your claim.

Costs related to use of a personal vehicle are reimbursed at a rate of $0.170 per kilometre.

To be eligible to reimbursement of travel expenses at a rate of $0.59 per kilometre, you must meet the following conditions:

You must present a medical certificate indicating your inability to use public transit because of injuries caused by the criminal act or the act of good citizenship.
You must have travelled after January 1, 2023, with a personal vehicle.
IVAC must authorize the reimbursement.

Claim expenses online

Download the form Expense Claim

Pharmacists (prophylactic medications)

Prophylactic medications can be dispensed free of charge to anyone with a prescription, even if they do not have an IVAC file.

If these medications are dispensed before the person’s file was deemed eligible, reimbursement will not be authorized by the automated payment service for prescription drug costs.

Pharmacists who dispense prophylactic medications free of charge may apply for reimbursement.

Claiming expenses online

complete the Bordereau de transmission – Frais de médicaments prophylactiques (PDF | 236 KB)(French only)
attach the documents requested in the section “Documents à transmettre obligatoirement” (original bills and receipts)
verify that all the documents requested are attached
send the documents electronically, by fax or by mail

Download the form Transmittal slip - Prophylactic drug expenses (PDF) | 54 Ko)

Authorization to send a copy of the file

Complete this form to allow IVAC to obtain the necessary medical and psychotherapeutic or psychosocial reports.

Download the form Authorization to send a copy of the file (PDF | 199 KB)

Communication authorization

Complete this form to authorize IVAC to obtain from or disclose to a treating healthcare professional any information deemed necessary for processing your applications.

Download the form Authorization to communicate (PDF | 181 KB)

Acceptance to act on behalf of the beneficiary

This form must be signed by the individual in charge of administering the amounts paid to a minor or disabled person of full age. IVAC sends the information to the Public Curator.

Download the form Acceptance to Act on Behalf of the Beneficiary (PDF | 294 KB)

Direct deposit

Complete this form to have the amounts paid by IVAC deposited into your bank account.

Download the form Direct Deposit Registration or Modification (PDF | 640 KB)

Application for financial assistance to contribute to the needs of a child born as the result of a sexual aggression

Complete this form to obtain financial assistance to help support for a child born as a result of a sexual assault.

Download the form Application for Financial Assistance to contribute to support for a Child Born as a Result of a Sexual Assault (PDF | 311 KB)

Please note that the amount of this financial assistance is paid out on the first day of each month following the birth date of the child. It can also be paid out retroactively if the application is submitted the month following the birth of the child.

Notice of change in situation

Complete this form to notify of a change in situation such as a change of address, changes in financial situation and requests, a parental change or any other change worthy of notification.

Please refer to the form for a list of these changes

Download the form Application for Notice of Change in Situation(PDF | 312 KB)

Withdrawal

Complete this form to notify if a withdrawal request is formulated in regards to the person who is a victim or the rescuer’s application filed with IVAC.

Download the form Notice of Withdrawal (PDF | 115 KB)

Representation Mandate

Complete this form if you wish to be represented by a third party to do any follow-up relative to your application with IVAC.

Download the form Representation mandate(PDF | 272 KB)

Application for review

Complete this form if you wish to challenge a decision rendered by IVAC.

Download the form Application for Review (PDF | 308 KB)

Withdrawal of an application for review

Complete this form if you no longer wish to review a decision for which you had requested a review.

Download the form Withdrawal of an application for review (PDF | 276 KB)

Payment of Indemnity Extension (LIVAC)

Fill out the appropriate form(s) at the beginning of each quarter or half-year to apply for an indemnity extension.

Fill out the applicable forms:

Power of Attorney

Fill out this form if you wish to have a mandatary, i.e. a person or organization, represent you with respect to your applications and contacts with IVAC.

Download the form Power of Attorney (PDF | 764 Ko)

Declaration of Non-receipt of Funds by the Named and Intended Beneficiary

Fill out this form if you are the beneficiary and have not received the funds. (This document must be sworn before a commissioner for oaths.)

Download the form Declaration of Non-receipt of Funds by the Named and Intended Beneficiary (PDF | 222 Ko)