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iA Financial Application

Fastest Underwriting!

iA Financial Application

Step 1 of 9

11%

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Email
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Spouse Email
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First Name
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Spouse First Name
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Last Name
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Spouse Last Name
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Tag 1
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Tag 2
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Main Form ID
Information About (You)
Full Address*

Address

Apt No (optional)

City

State / Province

ZIP / Postal Code

Country
Mailing Address
- Same as Above
Mailing Address*

Address

Apt No (optional)

City

State / Province / Region

ZIP / Postal Code

Country
Mobile Phone Number*
Identification
Identification*
Province/Territory of Issue*
Number*
Expiry Date*

MM slash DD slash YYYY

Insurance History for (You)
Do you have any other pending insurance applications?*
- Yes
- No
Have you ever been declined for insurance?*
- Yes
- No
Do you have an inforce insurance on your life, excluding group insurance or credit insurance?*
- Yes
- No

Declaration of insurability
A contract in good faith

iA Financial Group wishes to be a leading business partner for you. We are committed to providing coverage at the best possible conditions in order to offer financial security to you and your loved ones. Therefore, by answering the questions contained in this application, you hereby agree to provide complete and honest information. However, you are NOT required to disclose the medical conditions listed below:
- Acne
- Adenoids removal
- Allergies
- Contraceptives
- Cosmetic surgery without complications
- Hemorrhoids
- Menopause
- Otitis
- Pregnancy, delivery or miscarriage without complications
- Tonsils removal
- Vision impairment corrected by glasses or contact lenses
Tobacco Use for (You)
When was the last time you used tobacco in any form (including cigarettes, cigars, cigarillos, cannabis (marijuana) mixed with tobacco, electronic cigarettes, gum, patches, chewing tobacco or snuff, betel nuts, shisha, hookah / water pipe, etc.*
Birthplace for (You)
Were you born in Canada?*
- Yes
- No
What is your place of birth?
Have you lived in Canada for three (3) years or more?*
- Yes
- No
Have you lived in Canada for one (1) year or more*
- Yes
- No
What is your legal status?*

Occupation for (You)
What is your occupation?*
What is your annual income before taxes?*
What is the highest level of education you have completed?*
Prior Declarations for (You)
In the last 12 months, have you submitted a declaration of insurability (insurance application) to iA financial Group?*
- Yes
- No
Will you be cancelling any existing life insurance if this application is approved?*
- Yes
- No
Family History for (You)
Does a member of your family (father, mother, brother, sister) suffer or has ever suffered from one of the following conditions before the age of 65? You are not required to disclose a family history of hypertension and high cholesterol.*
- Cancer
- Diabetes
- Parkinson’s Disease
- Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
- Huntington’s chorea
- Hemophilia
- Death from an unknown cause
- Unknown since I was adopted or I have no contact with my family
- Cardiovascular disease (e.g. CVD, myocardial infarction)
- Multiple sclerosis
- Alzheimer’s disease
- Neurological disease (excluding epilepsy and depression)
- Polycystic kidney disease
- Any other hereditary disorder
- No
Specialists and Medication for (You)
In the last 5 years, have you consulted a specialist?*
- Yes
- No
In the last two (2) years, were you prescribed, or did you refill a prescription that you will need to take more than thirty (30) consecutive days?*
- Yes
- No

Neurological and Mental Health for (You)
In the last five (5) years, have you consulted or been treated for any mental illness (for example: depression, anxiety, personality disorder, suicide attempt, stress, insomnia)?*
- Yes
- No
Indicate the condition
Do you suffer from or have you ever been diagnosed with a disorder or disease of the nervous system or a neurological condition, including:*
- Alzheimer’s disease
- Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease)
- Autism spectrum disorder
- Cerebral palsy
- Cognitive or mental impairment
- Developmental disorder
- Down syndrome (Trisomy 21)
- Multiple sclerosis
- Parkinson’s disease
- Other disorders or diseases
- No, none
General Medical Conditions for (You)
In the past five (5) years, have you consulted or been treated for musculoskeletal disorders (for example: arthritis, tendinitis, back pain)?*
- Yes
- No
Do you suffer from or have you ever been diagnosed with one of the following diseases or disorders?*
- Aneurysm
- Any heart or blood vessel disorder
- Any type of diabetes or glucose intolerance
- Asthma and currently a smoker
- Bariatric surgery
- Cancer
- Cerebrovascular accident (stroke)
- Crohn’s disease / Ulcerative colitis
- Deafness
- Familial muscular disease (muscular dystrophy)
- Hepatitis B or C
- Hereditary disorder
- Herniated disc
- HIV / AIDS
- Malformation(s) and/or congenital disorder
- Sleep apnea
- Temporary loss of vision or blindness
- Transient ischemic attack (TIA)
- Tumor, cyst, nodule, mass, fibroma or polyp
- No, none

Investigation and Build for (You)
Are you currently under medical investigation, awaiting results, disabled or do you have any signs or symptoms for which you have not yet consulted a doctor or were advised to undergo a diagnostic test that has not yet been performed?*
- Yes
- No
In the last three (3) years, have you undergone any diagnostic tests including: ultrasound, resting or stress electrocardiogram (ECG), scintigraphy, scan, magnetic resonance imaging (MRI), biopsy, mammogram, colonoscopy, colposcopy, etc.?*
- Yes
- No
Height
Height
Weight
In the past year, have you lost more than 10lbs/5 kg (excluding weight loss following childbirth)?*
- Yes
- No
Weight Loss
Sports and Travel for (You)
In the next two (2) years, do you plan to travel or reside outside of Canada or the United States?*
- Yes
- No
Answer YES only if the total duration of your travel exceeds two (2) months.
In the last 4 weeks, have you travelled outside of Canada or have you transited through an airport?*
- Yes
- No
Are you experiencing symptoms of fever, cough, or difficulty breathing?*
- Yes
- No
In the last 4 weeks, have you or someone close to you been in contact with a confirmed or suspected case of COVID-19 coronavirus infection?*
- Yes
- No
In the last 12 months, have you been hospitalized for the COVID-19 coronavirus disease?*
- Yes
- No
In the past year, have you practiced aviation (other than as a passenger), scuba diving, parachuting, heli-skiing, a winter sport in avalanche risk areas, hang gliding, paragliding, mountaineering, climbing, car or motorcycle racing or plan to do so in the next year?*
- Yes
- No

Life Habits for (You)
Within the last five (5) years, has your driver’s license been suspended or revoked (excluding due to unpaid fines)?*
- Yes
- No
Within the last three (3) years, have you had four (4) or more driving violations (excluding parking tickets)?*
- Yes
- No
In the last ten (10) years have you been incarcerated, charged or convicted for any criminal offence?*
- Yes
- No
On average, do you consume more than twelve (12) alcoholic beverages per week? (One beverage = 1 bottle of beer or 1 glass of wine or 1 ounce of liquor)*
- Yes
- No
On average, in the past 12 months, have you used marihuana, cannabis or hashish more than once per week?*
- Yes
- No
Within the last ten (10) years, have you used any drug other than marijuana, cannabis or hashish (e.g. anabolic steroids, ecstasy, speed, GHB, magic mushrooms, cocaine, heroin, etc.)?*
- Yes
- No
Have you ever been treated for drug use, been a member of a support group or have ever been advised to reduce your consumption or to receive treatment for it?*
- Yes
- No

Beneficiary`s For (You)
Primary Beneficiary(s)
Full Name*

Date of Birth*

Gender*

Relationship*

Please specify

Share %*

Would you like to be able to change the beneficiary without having his/her consent?*
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Benficiary Full Name
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Benficiary Date of Birth
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Benficiary Gender
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Benficiary Relationship
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Benficiary Specify
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Benfeficiary Share
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Benfeficiary Consent
Contingent Beneficiary(s)
Would you like to add a Contingent Beneficiary to this coverage?*
- Yes
- No
Full Name*

Date of Birth*

Gender*

Relationship*

Please specify

Share %*
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Contingent Full Name
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Contingent Gender
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Contingent Relationship
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Contingent Specify
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Contingent Share
Trustee for all minor beneficiaries
Are any primary or contingent beneficiaries a minor?*
- Yes
- No
Full Name*

Regulatory Questions for (You)
Will the life insurance premiums be financed or paid by a lender or any other person who has no relationship with you?*
- Yes
- No
Are you a U.S. citizen or a U.S. resident for U.S. tax purposes?*
- Yes
- No
Are you a tax resident in another tax jurisdiction other than Canada or the United States?*
- Yes
- No
Billing For (You)

The first monthly premium will not be withdrawn until 1-2 weeks AFTER the policy is approved. A monthly premium will be withdrawn on the effective date of the policy monthly. (Example: Your policy is approved on March 13th, the first premium will be withdrawn around March 28th and the next on April 13th, then May 13th and so on.)

Providing your bank info today will not result in a payment being withdrawn. You may cancel your policy at any time without any penalty. If the policy is not approved for any reason no charges will be made to your bank account.
Name of Account Holder*
Branch no.*
Institution no.*
Account no.*
Name of Financial Institution*
How did you hear about us?
Other
*
- I agree to the Client Disclosure terms.

Terms of Use
Privacy Policy

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Affinity Life Inc., is an insurance brokerage licensed to sell life insurance products in Alberta and British Columbia. We are currently not available in other provinces. Policy obligations are the sole responsibility of the issuing insurance company. Coverage is subject to underwriting by the selected insurance company. Please see policy documents for full terms, conditions, and exclusions. The logos and trademarks used here are owned by the respective entities. Refer to our Privacy Policy and Terms of Use for additional information.

Terms of Use
Privacy Policy

Facebook-f Instagram Youtube Linkedin-in

Affinity Life Inc. is an insurance marketing agency that provides insurance products through a network of affiliated, licensed insurance agents across Canada. Policy obligations are the responsibility of the broker and the issuing insurance company. Coverage is subject to underwriting by the selected insurance company. Please see policy documents for full terms, conditions, and exclusions. The logos and trademarks used here are owned by the respective entities. Refer to our Privacy Policy and Terms of Use for additional information.