City of Calgary Settlement

All capitalized terms in this claim form are as defined in the Settlement Agreement.

This form must be completed and returned to the Claims Administrator with the proper supporting documentation no later than November 17, 2021.

The claimant certifies that he/she meet the definition of a Qualifying Member as defined in the Settlement Agreement below:

Qualifying Member means members of the Settlement Class who have made claims for compensation from the Reversionary Funds, met the Qualification Requirements, and whose claims for compensation from the Provable Mental Injury Fund have been allowed by the Claims Administrator in accordance with Part 7 of this Settlement Agreement.

By submitting this claim. the claimant acknowledges that he/she meets the definition of a Qualifying Member.

Criteria of a Qualified Member to receive compensation from the Reversionary Funds

  1. Claim for Mental Injury, to a maximum of $2,000. The required documentary support is attached:
    1. Settlement Class members must provide to the Claims Administrator, prior to the expiry of the Settlement Administration Period, a note or report from a treating medical doctor or psychologist, that includes sufficient information from which the Claims Administrator can determine, on a balance of probabilities:
      1. that the member suffers from a Condition and its diagnosis;
      2. how such Condition impacts the member’s physical, mental or emotional capacity and well-being;
      3. the Condition was caused in fact by the Disclosure; and
      4. That the Condition is a serious or prolonged trauma or illness, which rises above the ordinary annoyances, anxiety and fears experienced in daily life, as distinct from minor or transient upset, disgust, anxiety, agitation or other mental states that fall short of injury and shall not qualify for compensation.
      5. If the member suffered from the Condition prior to the Disclosure, that the Disclosure caused a deterioration or worsening of such Condition, and that any expenses claimed would not have been incurred but for the Disclosure.
    2. Claim for Treatment Charges and Expenses Fund to a maximum of $500.Copies of receipts and a written confirmation from the Qualifying Member attached:
      1. Amounts not covered by government or supplemental health care plans:
        1. Costs of prescribed medication;
        2. Costs of prescribed treatment;
        3. Costs of attending counselling sessions;
        4. Travel charges incurred to obtain prescribed medications or treatment.
      2. The above claimed above must be supported with the following:
        1. A doctor’s prescription for any medication, medical services or paramedical services expense claimed;
        2. Original, certified or reasonably verified to the satisfaction of the Claims Administrator, copies of each invoice and/or receipt claimed; and
        3. Written confirmation, signed by the Qualifying Member, that such expenses were not reimbursed by a third party.
    3. Claim for reimbursement of Document Procurements Costs to a maximum of $150.Copies of receipts attached:
      1. Costs of obtaining medical reports and/or a doctor’s note, for the purpose of applying to the Claims Administrator for payment from the Reversionary Funds.

Questions and completed forms can be forwarded to [email protected]