Form 382-A - Application For Reimbursement Of Expenses Page 2

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APPLICATION FOR REIMBURSEMENT OF EXPENSES
Occupational health and safety
a
For worker
For person accompanying the worker
Other
1. Information about the person applying for reimbursement
2. Information about worker
Surname (as shown on birth certificate) and first name
Telephone
Worker’s file No.
1 0 3 9 4 0 3 3 8
Tremblay, Pierre
Home Adress, Number, Street, Apt.
Date of original event
2 0 1 1
Y Y Y Y
M M
0 4 2 2
D D
1151 Hill Street
City, Province, Country
Date of recurrence,
Postal code
2 0 1 2
Y Y Y Y
0 1 0 8
M M
D D
Québec (Québec)
Canada
relapse or aggravation
3. Travel Expenses (attach original receipts)
Date
Amount Claimed
Reason for travel
Distance
Method of
To
From
of round
transportation used
Physio
Occ.
Transpor-
Parking
Other (Specify)
trip (km)
Month
Day
Therapy
a
(√)
tation
and tolls
(√)
01 22
Home
Physio Clinic
bus
5,20
01 23
Home
Hospital
Doctor appointment
car
32
4,64
2,50
CNESST Regional Offices
Just one number for the CNESST:
1 844 838-0808
Abitibi-Témiscamingue
Côte-Nord
Île-de-Montréal
Longueuil
Saint-Jean-sur-Richelieu
33, rue Gamble Ouest
Bureau 236
1, complexe Desjardins
25, boulevard La Fayette
3
étage
e
Rouyn-Noranda
700, boulevard Laure
Tour Sud, 31
étage
Longueuil
145, boulevard Saint-Joseph
e
Sept-Îles
Saint-Jean-sur-Richelieu
(Québec) J9X 2R3
Case postale 3
(Québec) J4K 5B7
Fax: 819 762-9325
(Québec) G4R 1Y1
Succursale Place-Desjardins
Fax: 450 442-6373
(Québec) J3B 1W5
Fax: 418 964-3959
Montréal
Fax: 450 359-1307
Mauricie et Centre-du-Québec
2
étage
(Québec) H5B 1H1
e
If the worker must be accompanied, attach the medical prescription to that effect and indicate:
1185, rue Germain
235, boulevard La Salle
Fax: 514 906-3200
Bureau 200
Valleyfield
Val-d’Or
Surname (as shown on birth certificate) and first name of person accompanying the worker
Baie-Comeau
Services spécialisés
Telephone
1055, boulevard des Forges
9, rue Nicholson
Advance received
$
(if applicable)
Trois-Rivières
Salaberry-de-Valleyfield
(Québec) J9P 6B1
(Québec) G4Z 2Z4
Téléc. : 514 906-3232
Fax: 819 874-2522
Fax: 418 294-7325
Indemnisation et réadaptation
(Québec) G8Z 4J9
(Québec) J6T 4M4
Home Adress, Number, Street, Apt.
City, Province, Country
Signature of person
Y Y Y Y
M M
D D
Téléc. : 514 906-3434
Fax: 819 372-3286
Fax: 450 377-8228
applying for reimbursement
Bas-Saint-Laurent
Estrie
Detach and return to the CNESST
180, rue des Gouverneurs
Place-Jacques-Cartier
Lanaudière
Outaouais
Yamaska
Case postale 2180
Bureau 204
432, rue De Lanaudière
15, rue Gamelin
2710, rue Bachand
3 8 2 - A
(2016-09)
Rimouski
1650, rue King Ouest
Case postale 550
Case postale 1454
Saint-Hyacinthe
(Québec) G5L 7P3
Sherbrooke
Joliette
Gatineau
(Québec) J2S 8B6
Fax: 418 725-6237
(Québec) J1J 2C3
(Québec) J6E 7N2
(Québec) J8X 3Y3
Fax: 450 773-8126
Fax: 819 821-6116
Fax: 450 756-6832
Fax: 819 778-8699
Capitale-Nationale
425, rue du Pont
Gaspésie–Îles-de-la-Madeleine
Laurentides
Saguenay–Lac-Saint-Jean
Case postale 4900
163, boulevard de Gaspé
3
étage
Place-du-Fjord
e
Gaspé
Succursale Terminus
275, rue Latour
901, boulevard Talbot
Québec
(Québec) G4X 2V1
Saint-Jérôme
Case postale 5400
Saguenay
(Québec) G1K 7S6
Fax: 418 368-7855
(Québec) J7Z 0J7
Fax: 418 266-4015
Fax: 450 432-1765
(Québec) G7H 6P8
200, boulevard Perron Ouest
Fax: 418 545-3543
Chaudière-Appalaches
New Richmond
Laval
835, rue de la Concorde
(Québec) G0C 2B0
1700, boulevard Laval
Complexe du Parc
Lévis
Fax: 418 392-5406
Laval
6
étage
e
(Québec) G6W 7P7
(Québec) H7S 2G6
1209, boulevard du Sacré-Cœur
Fax: 418 839-2498
Fax: 450 668-1174
Case postale 47
Saint-Félicien
(Québec) G8K 2P8
Fax: 418 679-5931
For information: Call your CNESST regional office.
You can print this form from our website
Always give your name, telephone number, health insurance card number, the date of the work-related event and your file number.
, by clicking
on Forms.

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