Skip to content
Need help? Give us a call
Book a Call
Need help? Give us a call
Book a Call
Extreme Sports Insurance Application
Extreme Insurance Application (CPP and iA)
Step
1
of
10
10%
Hidden
Email
Hidden
First Name
Hidden
Last Name
Hidden
Tag 1
Hidden
Tag 2
Hidden
CPP Code
Hidden
IFA Code
Hidden
Main Form ID
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What is your Citizenship?
*
Canadian
Permanent Resident
Work Permit
International Student
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Mailing Address
Same as Above
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Mobile Phone Number
*
Identification
Type
*
Type
Driver’s License
Passport
Citizenship
Permanent Resident Card
Province Identification Card
Birth Certificate
Province/Territory of Issue
*
Province/Territory of Issue
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
*
Select
Male
Female
Other
Relationship
*
Select
Partner
Spouse
Ex-spouse
Brother
Sister
Child
Other
Please specify
Share %
*
Would you like to be able to change the beneficiary without having his/her consent?
*
Select
Yes (Revocable)
No (Irrevocable)
Add Another Beneficiary
-
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
*
Select
Male
Female
Other
Relationship
*
Select
Partner
Spouse
Ex-spouse
Brother
Sister
Child
Other
Please specify
Share %
*
Add another beneficiary
-
Hidden
Contingent Full Name
Hidden
Contingent Gender
Hidden
Contingent Relationship
Hidden
Contingent Specify
Hidden
Contingent Share
Trustee for All Minor Beneficiaries
If 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
Relationship
Select
Partner
Spouse
Ex-spouse
Brother
Sister
Child
Other
Please specify
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Account Type
*
Chequing
Savings
Withdrawal Date
*
1
8
15
22
28
Withdrawals Are
*
Personal-Related
Business-Related
How did you hear about us?
Select
YouTube
Social Media
Google
Advertising
Friend/Colleague
Alpine Club of Canada
TABVAR
Association of Canadian Mountain Guides
Other
Othere
*
I agree to the
Client Disclosure
terms.