iA Financial Application

Fastest Underwriting!

iA Financial Application

Step 1 of 9

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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?*

Beneficiary`s For (You)
Primary Beneficiary(s)Your primary beneficiary(s) are first in line to receive the life insurance proceeds in the event of your death. If you have one beneficiary then they will receive 100% of the proceeds, and if you have several beneficiaries it will be split between them depending on the share percentage you choose.
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)Your contingent beneficiary(s) are only in the event that your primary beneficiary(s) are deceased. If your primary beneficiary(s) have passed away then your contingent beneficiary(s) will receive the life insurance proceeds. If your contingent beneficiary(s) are also deceased or you didn’t name any then your estate will be the beneficiary for your life insurance proceeds and will be distributed according to your will. If you do not have a will then it will be distributed according to provincial laws which vary province to province.
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 beneficiariesIf any of your primary or contingent beneficiaries are minors you will need to add a trustee for them. In the event of your death, this trustee will manage the life insurance proceeds on behalf of the minors until they reach age of majority. Upon age of majority they will have access to the life insurance funds and any accumulated capital from investments.
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
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- I agree to the Client Disclosure terms.

iA Financial Application

iA Financial Application

Step 1 of 9

Information About (You)

Insurance History for (You)

Declaration of insurability

Tobacco Use for (You)

Birthplace for (You)

Occupation for (You)

Prior Declarations for (You)

Family History for (You)

Specialists and Medication for (You)

Neurological and Mental Health for (You)

General Medical Conditions for (You)

Investigation and Build for (You)

Sports and Travel for (You)

Life Habits for (You)

Beneficiary`s For (You)

Regulatory Questions for (You)

Billing For (You)