iA Financial Application

Fastest Underwriting!

Step 1 of 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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Tag 3
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Main Form ID
Information About (You)
Full Address*
Address Apt No (optional) City State / Province / Region 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
Information About (Spouse)
Full Address*
Address Apt No (optional) City State / Province / Region ZIP / Postal Code Country
Mailing Address
- Same as Above
Mailing Address*
Address Apt No (optional) City State / Province / Region ZIP / Postal Code Country
Identification
Identification*
Province/Territory of Issue*
Number*
Expiry Date*
MM slash DD slash YYYY

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

Occupation for (You)
What is your occupation?*
What is your annual income before taxes?*The annual income before taxes includes the following income: Employment income, pensions, annuities, and income from financial investments.
What is the highest level of education you have completed?*
Occupation for (Spouse)
What is your occupation?*
What is your annual income before taxes?*The annual income before taxes includes the following income: Employment income, pensions, annuities, and income from financial investments.
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?*Only answer “Yes” if you’re cancelling personal life insurance. If you are cancelling group life insurance from your work and/or mortgage insurance you will answer “No”.
- Yes
- No
Prior Declarations for (Spouse)
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?*Only answer “Yes” if you’re canceling personal life insurance. If you are canceling group life insurance from your work and/or mortgage insurance you will answer “No”.
- Yes
- No

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*
Beneficiary`s For (Spouse)
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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Spouse Benficiary Full Name
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Spouse Benficiary Date of Birth
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Spouse Benficiary Gender
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Spouse Benficiary Relationship
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spouse Benficiary Specify
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Spouse Benficiary Share
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Spouse 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 beneficiaries
Are any primary or contingent beneficiaries a minor?*
- Yes
- No
Full Name*

iA Financial Application

Step 1 of 11

Information About (You)

Information About (Spouse)

Insurance History for (You)

Insurance History for (Spouse)

Declaration of insurability

Tobacco Use for (You)

Tobacco Use for (Spouse)

Birthplace for (You)

Birthplace for (Spouse)

Occupation for (You)

Occupation for (Spouse)

Prior Declarations for (You)

Prior Declarations for (Spouse)

Family History for (You)

Family History for (Spouse)

Specialists and Medication for (You)

Specialists and Medication for (Spouse)

Neurological and Mental Health for (You)

Neurological and Mental Health for (Spouse)

General Medical Conditions for (You)

General Medical Conditions for (Spouse)

Investigation and Build for (You)

Investigation and Build for (Spouse)

Sports and Travel for (You)

Sports and Travel for (Spouse)

Life Habits for (You)

Life Habits for (Spouse)

Beneficiary`s For (You)

Beneficiary`s For (Spouse)

Trustee for all minor beneficiaries

Regulatory Questions for (You)

Regulatory Questions for (Spouse)

Billing for (You)

Billing for (Spouse)