Notice to the reader: This document complies with the S G Q R I 0 0 8 - 0 2 standard of the Government of Quebec on the accessibility of a downloadable

document.
If you are experiencing difficulties, contact us at: 1 800 3 6 1 – 7 6 2 0.

Power of attorney (individual only)

BEFORE FILLING OUTTHIS FORM, PLEASE READTHE INFORMATION ON PAGE 2.
Fill out the form in printed characters.

SECTION 1 (Fill out and sign for any transaction)

Information about the principal and the agent
PRINCIPAL (individual who is represented)
Name First name Quebec driver's license number

Complete address

(No identification required) Date of birth

Permit reference number Year Month Day
OU Provide one of the pieces
driving in Quebec of identity indicated on page 2)
MANDATORY (an adult natural person who agrees to represent the principal)
Name First name Quebec driver's license number

Complete address

Power of attorney
I, the undersigned, the principal, authorize the above-designated agent to represent me for the following transaction:

Describe here the requested transaction [e.g.: renewal of driver's license or registration,

.
vehicle transfer, replacement of registration certificate, storage, withdrawal from service.

This power of attorney is valid until .

I signed the present at , the .
(Place of signature) (Date)

Signature of the principal Telephone

SECTION 2 (Fill out for any transaction concerning a vehicle)

Vehicle description
Brand Model Year License plate number

Vehicle identification number (VIN)

SECTION 3 The principal must complete and sign the declaration that concerns him [A or B], only during a transfer.
Transfer declaration
A) Declaration of the CEER who is being represented (principal)
I declare that I have: sold my vehicle for the amount of: $.
(check the appropriate box)
gave my vehicle.

Name of the new owner (in capital letters):

Signature of the transferor

B) Declaration of the PURCHASER who is being represented (principal)

I declare that the odometer indicates (check the appropriate box) kilometers thousand

Signature of the buyer

Quebec Automobile Insurance Corporation
549830(2016-06) Page1of2
 Information on the use of the proxy
The power of attorney must be completed, signed, and dated by the person who cannot attend (principal) at the Company of
the automobile insurance of Quebec and who wishes to authorize another person (mandatary) to act on their behalf
transaction related to his file. Once filled out, it contains confidential information that could be used
for other purposes. Therefore, the Company recommends that you grant a power of attorney only to a trusted person.
who you trust and keep a copy.

General instructions
A power of attorney that is not filled out according to the instructions or on which inscriptions are erased, crossed out or
modified will be refused.
If the person being represented chooses to enter their date of birth in the 'MANDANT' section of the...
1, she must provide her representative with an original identification document accepted by the Company1No identity document
is not required if the reference number of their Quebec driver's license is provided.
A fax or a photocopy of the duly completed form can only be accepted if the signature(s)
required are original.
The agent (the person who represents the principal) must be 18 years old or older and must present an identification document.
identity accepted by the Company1.
– Vehicle registered in joint ownership (co-ownership or shared accommodation): For any transaction other than a vehicle transfer,
one of the persons whose name is included in the name of the condominium or cohabitation indicated on the certificate
registration must present or provide a proxy. Contact the Company to learn about the
obligations that apply to the transfer of such a vehicle2.
Additional instructions for vehicle transfer
If you grant a power of attorney because:
Do you sell or give away your vehicle:
–– Fill out and sign sections 1, 2, and 3A.
Remember that you remain responsible for the vehicle until it is registered in the name of the new owner.
Owner. It is your responsibility to ensure that the registration has been made in the name of the buyer.
You are acquiring a vehicle:
–– Fill out and sign sections 1, 2, and 3B.
If the buyer is absent, the transfer transaction will be refused to their representative if the declared mileage is
Section 3B is lower than that declared during the previous registration. The buyer may then request some
explanations to his seller or to present himself in person if he still wishes to allow the Company to proceed with the
transfer.
Furthermore:
Before proceeding with the transfer, verify that the vehicle can be registered by calling 1 900 565-1212.
or by using the online service "Check the right to register a vehicle" on the company's website:
saaq.gouv.qc.caFees are required for each consultation.
For the donation or sale of a registered vehicle in Quebec between related individuals, both parties must present:
√ the formDeclaration of transaction between related individuals regarding a registered road vehicle
Quebec (VD-80.1)of Revenu Québec, duly completed;
a document proving the link2.
1. Original identification documents accepted by the Company
–– Permit authorizing the driving of a vehicle Permanent resident card Taxi driver license
Identification card for examination issued by Passport Identity card of a peace officer
the Company Certificate of Indian Status Identity card of a member of
Canadian citizenship certificate with photo Health insurance card Canadian Forces

2. For any additional information or to know the accepted documents for proof of relationship, contact the Center.
customer relations with the Company at 418 643-7620 (Quebec), at 514 873-7620 (Montreal) or at 1 800 361-7620
(Quebec, Canada, United States), or visit the company's websitesaaq.gouv.qc.ca).
The communication of personal information
Authorized personnel of the Quebec Automobile Insurance Corporation handles the personal information entrusted to them confidentially.
They are essential for applying the Automobile Insurance Act, the Société de l'assurance automobile du Québec Act, and the Safety Code.
road. The Company communicates this information to its agents and to certain ministries and agencies, according to the Access to Documents Act
of public bodies and on the protection of personal information. This information may also be used for statistical, study purposes,
of survey, inquiry or verification. Failing to provide them may result in a refusal of the requested service. You can consult the
personal information concerning you, to obtain a copy or have it corrected. For more information, consult the Policy of
Company confidentialitysaaq.gouv.qc.caYou are calling the Customer Relations Center of the Company.

Quebec Automobile Insurance Corporation

549830(June 2016) Page 2 of 2