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Extreme Sports Insurance Application

Extreme Insurance Application (CPP and iA)

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IFA Code
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Personal Information and Prequalification for (You)
Within the past 12 months, have you used by any means, a substance or product containing tobacco or nicotine (excluding cigars), or have you smoked (including electronic vaporizer or “vaping”) marijuana more than six times per week?*
- Yes
- No
Country of Birth*
Country
What is your Citizenship?*
Occupation
Will premiums be stopped, or coverage be reduced or discontinued on any existing life insurance coverage or annuity if the insurance applied for in this application is issued?*
- Yes
- No
Height
Height
Weight
Full Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
- Same as Above
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Identification
Type*
Province/Territory of Issue*
Number*
Expiry Date*
MM slash DD slash YYYY
Are you a U.S. Resident for tax purposes, or a U.S. citizen, and/or a resident of another country for tax purposes?*
- Yes
- No
Do you have a physician?*
- Yes
- No
Physician's name:
Address of your physician:

Medical Questions Part 1 for (You)
Do you require assistance with 2 or more of the activities of daily living, such as, but not limited to, getting up, walking, bathing, showering, washing, toileting, taking medication, dressing or feeding?*
- Yes
- No
Are you a resident of a long-term care facility, nursing home, nursing facility or assisted living residence?*
- Yes
- No
Are you bedridden or wheelchair bound, regardless of your place of residence?*
- Yes
- No
Have you ever been advised to receive, or are you on a waiting list for, or are you the recipient of, an organ or bone marrow transplant (excluding corneal transplant)?*
- Yes
- No
Within the last 60 days, have you been admitted to a hospital for more than 48 consecutive hours (excluding pregnancy)?*
- Yes
- No
Have you ever been advised to have surgery or a procedure, or an investigation or diagnostic test of any type (excluding annual tests with normal results), or to consult with a medical professional or facility, that has not yet started or been completed or the result of which is not yet known?*
- Yes
- No
Have you ever not followed treatment or not taken medication advised or prescribed by a medical professional?*
- Yes
- No
Within the last 60 days have you had or been advised of an abnormal test result that changed existing treatment or resulted in new treatment for an ongoing condition?*
- Yes
- No
Have you ever tested positive for Human Immunodeficiency Virus (HIV) or had or been told you have, or been treated for, Acquired Immunodeficiency Syndrome (AIDS), Aids Related Complex (ARC), or a disease or disorder of the immune system excluding lupus, rheumatoid arthritis or type 1 diabetes?*
- Yes
- No
Have you ever had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for:
a) metastatic cancer, a recurrence of cancer, or a second diagnosis of cancer (excluding basal cell carcinoma) or*
- Yes
- No
b) a chronic lung or respiratory condition (excluding sleep apnea), such as, but not limited to, Chronic Obstructive Pulmonary Disease (COPD), emphysema, or pulmonary fibrosis, which requires or required the periodic use of oxygen, or the use of a steroid (excluding steroid treatment for asthma) or*
- Yes
- No
c) dementia, Alzheimer’s, memory loss, Muscular Dystrophy, myotonic dystrophy, Parkinson’s disease, Huntington’s Chorea or Amyotrophic Lateral Sclerosis (ALS) or*
- Yes
- No
d) congestive heart failure, systolic or diastolic heart failure or cardiomyopathy?*
- Yes
- No
Prior to age 40, have you had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, atherosclerosis, stroke (CVA), transient ischemic attack (TIA), chronic kidney disease, an aneurysm anywhere in your body or had heart bypass surgery, angioplasty or stent insertion?*
- Yes
- No
Within the last 12 months, have you:
a) used (except as prescribed by a medical professional) a narcotic or barbiturate or*
- Yes
- No
b) used (whether prescribed by a medical professional or not) heroin, a psychoactive drug, cocaine, crack, methadone, fentanyl or another similar agent or*
- Yes
- No
c) been in a hospital or facility for drug or alcohol treatment?*
- Yes
- No
Within the last 24 months, have you been convicted, incarcerated, on probation or parole, or is a charge pending or are you awaiting sentencing, for a criminal offence?*
- Yes
- No
Have you ever been diagnosed with a life threatening, critical, or terminal condition for which a medical professional has estimated that you have a reduced life expectancy?*
- Yes
- No

Medical Questions Part 2 for (You)
Within the last 3 years, have you had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication, or had surgery or a procedure for:
a) cardiac chest pain (angina), heart attack (myocardial infarction), cardiac disease, valvular disease or disorder, heart rhythm disorder, coronary artery disease, atherosclerosis or disorder of a blood vessel, an aneurysm anywhere in your body, stroke (CVA) or transient ischemic attack (TIA) or a pacemaker or defibrillator, or had heart bypass surgery, angioplasty, stent insertion or valve surgery or*
- Yes
- No
b) circulatory problems in the legs and/or feet (peripheral vascular, arterial and/or neuropathy)?*
- Yes
- No
Within the last 12 months, have you had or been told you have, or been investigated (with a positive or unknown result) or treated for, cancer (of any type excluding basal cell carcinoma), an abnormal growth or a malignant tumour?*
- Yes
- No
Have you ever had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for:
a) chronic kidney disease such as, but not limited to, diabetic nephropathy, polycystic kidney disease (PKD), chronic renal failure at any stage, or been advised to be investigated for PKD or*
- Yes
- No
b) have a parental family history of PKD and you have not yet been investigated for PKD or*
- Yes
- No
c) liver disease such as, but not limited to, cirrhosis or hepatitis (excluding hepatitis A and B) or*
- Yes
- No
d) chronic or hereditary pancreatitis?*
- Yes
- No
Within the last 12 months, have you been in a hospital or other facility for more than 24 consecutive hours for a mental health condition such as, but not limited to, depression, anxiety or psychosis?*
- Yes
- No
Are you age 29 or under and have you ever had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for diabetes or your blood sugar level (excluding gestational diabetes)?*
- Yes
- No
Have you ever had or been told you have, or been investigated (with a positive or unknown result), or treated, or taken medication, or advised to take or prescribed medication for diabetes and any of the following: coronary artery disease, cardiac chest pain (angina), heart attack (myocardial infarction), stroke (CVA), tingling or burning or loss of sensation in an extremity (neuropathy), peripheral vascular or arterial disease, loss of vision (retinopathy), kidney disease (nephropathy), or had heart bypass surgery, angioplasty, stent insertion or amputation?*
- Yes
- No
Do you have a congenital development disorder such as, but not limited to, Down’s Syndrome or Autism?*
- Yes
- No

Medical Questions Part 3 for (You)
Have you ever had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for bipolar disorder, schizophrenia, manic-depression or psychosis?*
- Yes
- No
Within the last 5 years, have you been treated or received medical advice or counseling for, or been advised to seek treatment for, or to cease or reduce, the use of alcohol or drugs?*
- Yes
- No
Within the last 5 years, have you:
a) used (except as prescribed by a medical professional) a narcotic or barbiturate or*
- Yes
- No
b) used (whether prescribed by a medical professional or not) heroin, psychoactive drug, cocaine, crack, methadone, fentanyl or another similar agent or*
- Yes
- No
c) been in a hospital or facility for drug or alcohol treatment?*
- Yes
- No
Within the last 5 years, have you had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for a chronic lung or respiratory condition (excluding asthma) such as, but not limited to, chronic obstructive pulmonary disease (COPD), emphysema or pulmonary fibrosis?*
- Yes
- No
Within the last 5 years, have you been convicted, incarcerated, on probation or parole, or are you awaiting sentencing, for a criminal offence?*
- Yes
- No
After the age of 40, have you had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for a neurological condition such as, but not limited to, a. epilepsy or b. multiple sclerosis or c. seizures with loss of consciousness?*
- Yes
- No
Within the last 5 years, have you had or been told you have, or been investigated (with a positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication, or had surgery or a procedure for:
a) cardiac chest pain (angina), heart attack (myocardial infarction), cardiac disease, valvular disease or disorder, heart rhythm disorder, coronary artery disease, atherosclerosis or disorder of a blood vessel, an aneurysm anywhere in your body, stroke (CVA) or transient ischemic attack (TIA) or a pacemaker or defibrillator, or had heart bypass surgery, angioplasty, stent insertion or valve surgery or*
- Yes
- No
b) circulatory problems in the legs and/or feet (peripheral vascular, arterial and/or neuropathy)?*
- Yes
- No
Do you have diabetes that was diagnosed 20 or more years ago and within the last 12 months have you taken insulin or been advised to take or prescribed insulin?*
- Yes
- No
Do you have diabetes and within the last 6 months:
a) has insulin been taken, advised or prescribed as a new treatment or*
- Yes
- No
b) has the prescribed dosage of insulin been increased or*
- Yes
- No
c) has another form of insulin been added to the treatment plan?*
- Yes
- No
Do you plan to travel outside North America, the Caribbean, Australia, the United Kingdom, New Zealand or the European Union countries for more than 12 consecutive weeks in the next 12 months?*
- Yes
- No
Within the last 12 months, have you had a weight loss of 10% or more of your body weight, other than due to intentional dieting?*
- Yes
- No
Within the last 12 months, have you had unexplained blood in your urine or stool?*
- Yes
- No
Within the last 10 years, have you had or been told you have, or been investigated (with a positive or unknown result) or treated for, cancer (of any type excluding basal cell carcinoma), an abnormal growth or a malignant tumour?*
- Yes
- No

Medical Questions Part 4 for (You)
In your lifetime, have you been diagnosed and/or treated for any of the following conditions:
Acquired immunodeficiency syndrome (AIDS) or tested positive for the human immunodeficiency virus (HIV)?*
- Yes
- No
Heart rhythm disorder (arrhythmias) which required the insertion of a pacemaker, heart failure or cardiomyopathy?*
- Yes
- No
Cystic fibrosis, Alzheimer’s disease, dementia, Huntington’s chorea, Parkinson’s disease, amyotrophic lateral sclerosis (Lou Gehrig’s disease), muscular dystrophy, myotonic dystrophy or any form of ataxia?*
- Yes
- No
Chronic respiratory disease (excluding sleep apnea) which requires the daily administration of oxygen?*
- Yes
- No
Within the last three (3) years, have you had or been treated for leukemia, lymphoma, malignant tumour or any form of cancer (other than basal cell carcinoma)?*
- Yes
- No
Within the last twelve (12) months:
Have you been found guilty of a criminal offence (including offences associated with driving under the influence – DUI) or of a criminal offence awaiting trial?*
- Yes
- No
Have you used any hard drugs except as prescribed by a physician or have you used methadone prescribed or not by a physician?*
- Yes
- No
Are you presently:
Hospitalized or in a nursing facility including a centre or a home for individuals with reduced autonomy?*
- Yes
- No
Bedridden or wheelchair bound?*
- Yes
- No
Undergoing or waiting for an investigation for diagnostic purposes?*
- Yes
- No

Medical Questions Part 5 for (You)
Within the last five (5) years:
Have you had an amputation as a result of a disease?*
- Yes
- No
Have you had or been treated for a chronic kidney disease or a chronic liver disease (including cirrhosis, fibrosis, hepatitis C or any other types of chronic hepatitis)?*
- Yes
- No
Have you received an organ transplant or a bone marrow transplant or were you advised to do so due to your condition?*
- Yes
- No
Have you been treated for drug or alcohol use, joined a support group or been advised to reduce your consumption or to receive treatment for it?*
- Yes
- No
Within the last three (3) years:
With regards to heart attack (myocardial infarct), angina or heart valve disease:
Have you been diagnosed and/or been treated with anticoagulants?*
- Yes
- No
Have you undergone a surgery (including bypass, angioplasty, insertion of a stent or a prosthesis) or are you awaiting such surgery?*
- Yes
- No
with regards to cerebrovascular disease (stroke), transient ischemic attack (TIA) or vascular disease of the arms and/or legs (excluding varicose veins and superficial phlebitis):
Have you been diagnosed and/or been treated with anticoagulants?*
- Yes
- No
Have you had or are you awaiting surgery?*
- Yes
- No
Within the last twelve (12) months:
With regards to depression or any mental health disorder:
Have you been hospitalized?*
- Yes
- No
Has your medication been changed (addition or replacement of a medication, increase or decrease of dosage)?*
- Yes
- No
Have you ceased your medication without being advised by your doctor to do so?*
- Yes
- No
Have you undergone a surgery for an aneurysm or are you awaiting such surgery?*
- Yes
- No
If you have diabetes, has your medication changed as advised by a physician (addition or replacement of a medication, increase or decrease of dosage)?*
- Yes
- No

Medical Questions Part 6 for (You)
Within the last five (5) years:
Have you had or been treated for leukemia, lymphoma, malignant tumour or any form of cancer (other than basal cell carcinoma)?*
- Yes
- No
Within the last twelve (12) months, has your weight decreased by 10% or more (excluding after a diet or childbirth)?*
- Yes
- No
Within the next two (2) years:
Do you foresee travelling to high risk regions or regions of conflict or war?*If not sure, please consult the list of countries classified “Avoid all travel” or “Avoid non-essential travel” on the official Government of Canada website: http://travel.gc.ca/travelling/advisories
- Yes
- No
Do you intend to reside outside Canada or the USA for at least six (6) consecutive months?*
- Yes
- No
Family History:
Has one member of your immediate family (father, mother, brother, sister) been diagnosed with any of the following conditions: Huntington’s disease or polycystic kidney disease before age 60?*
- Yes
- No

General Declarations for (You)
Do you have any Access Life simplified life insurance coverage with Industrial Alliance Insurance and Financial Services Inc. that is either active or currently under review?*
- Yes
- No
Will the insurance applied for replace any other insurance currently in force, except for Access Life?*
- Yes
- No
We, the insured and the policyholder:
declare that all the answers and explanations provided in this electronic application and/or the declaration of health are true and complete and they constitute the basis for the insurance coverage;*
- Yes
- No
understand and accept that, if any misrepresentation or material omission is made, the insurer shall not be held to any obligation under any insurance that may be issued upon acceptance of our insurance application. Any misrepresentation may result in cancellation of the insurance;*
- Yes
- No
understand and accept that all benefits payable are subject to the conditions, definitions, limitations and exclusions set out in the contract, and we confirm that our advisor has had the opportunity to explain the details thereof to us;*
- Yes
- No
understand and agree that the coverage applied for in this application will take effect on the date that the application is received at the Insurer's Montreal office of iA Financial Group, provided that the application is accepted without modification, that the premium has been paid and honoured, that all required approvals have been received, and that there has been no change in the insurability of the insured persons between the date the application was signed and the date it is accepted. Only the coverage duly approved by the insurer will take effect;*
- Yes
- No
understand that transmitting the combination of our name with the confirmation code received by email or by SMS constitutes an electronic signature.*
- Yes
- No
iA Financial group, its affiliates and their agents can access information about me in order to know me better, better meet my needs and offer the best possible service and client experience. (If you do not wish to allow this access, please write to livingbenefits@ia.ca.)

Beneficiary Information 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?*
Hidden
Benficiary Full Name
Hidden
Benficiary Date of Birth
Hidden
Benficiary Gender
Hidden
Benficiary Relationship
Hidden
Benficiary Specify
Hidden
Benfeficiary Share
Hidden
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 %*
Hidden
Contingent Full Name
Hidden
Contingent Gender
Hidden
Contingent Relationship
Hidden
Contingent Specify
Hidden
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

Billing (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.
Banking Information
Name of Account Holder*
Branch no*
Institution no*
Account no*
Name of Financial Institution*
Address of Financial Institution
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Account Type*
Withdrawal Date*
Withdrawals Are*
How did you hear about us?
Othere
*
- I agree to the Client Disclosure terms.

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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.