Information Sheet

Information Sheet
Name*

First NameLast Name
Email*
example@example.com
SIN Number:*
SIN Expiry Date (if any)

MonthDayYear
Date
Occupation/Job Title:*
Brief Job Duties:*
Date of Employment Began:*

MonthDayYear
Date
Employer Name:*
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beneficiaries Information*
Do you want to add any Trustee?*

YesNo
Trustee Name:*

First NameLast Name
Contingent Beneficiaries Information
Have you ever applied for any type of insurance before? Was it Declined or Rated for any reason?*
Plans Chosen*
Any Other Comments about Chosen Plans (Meeting Notes):*

Health and Lifestyle Questions
When was the last time you used tobacco in any form (including cigarettes, cigars, cigarillos, marijuana/cannabis mixed with tobacco, electronic cigarettes, gum, patches, chewing tobacco or snuff, betel nuts, shisha, hookah/water pipe, etc.)?*
What product and how many times in last 12 months, or frequency?*
What is your country of birth?*
Have you lived in Canada for at least 3 years?*

YesNo
Date of Arrival in Canada, (put 01-01-1900 if not known and more than 3 years, REQUIRED IF LESS THAN 3 YEARS)*

MonthDayYear
Date
What is your legal status in Canada?*
Immigration Document, if applicable (Study Permit/Work Permit)

Cancelof
Highest level of Education: (Diploma, Apprenticeship Program, Undergraduate Certificate, Postgraduate Degree, High school or equivalent, College, Bachelor’s Degree)*
Have you sought medical attention or received treatment for or been told you have symptoms of any of the following diseases or disorders?*
List*
A contract in good faith
iA Financial Group wishes to be a leading business partner for you. We are committed to providing coverage with 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
- Adenoid removal
- Allergies
- Contraceptives
- Cosmetic surgery without complications
- Hemorrhoids
- Menopause
- Otitis
- Pregnancy, delivery or miscarriage without complications
- Tonsil removal
- Vision impairment corrected with glasses or contact lenses
Has any member of your family (father, mother, brother, sister) suffered from one of the following conditions before the age of 65? You are not required to disclose a family history of hypertension, high cholesterol or depression.*
- Cancer
- Multiple sclerosis
- Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
- Polycystic kidney disease
- Death from an unknown cause
- Cardiovascular or cerebrovascular disease (e.g.: stroke, CVD, TIA)
- Parkinson’s disease
- Neurological disease (excluding epilepsy)
- Hemophilia
- Diabetes
- Alzheimer’s disease
- Huntington’s chorea
List*
In the last five (5) years, have you consulted a specialist? (Please refer to the list below.)*

YesNo
We consider the following doctors as specialists:
- Cardiologist
- Dermatologist
- Endocrinologist
- Gastroenterologist
- Geriatrician
- Gynecologist
- Hematologist
- Internist (Internal medicine)
- Neonatologist
- Nephrologist
- Neurologist
- Oncologist
- Ophthalmologist
- Otorhinolaryngologist (ENT)
- Pneumologist
- Psychiatrist
- Radiologist
- Rheumatologist
- Surgeon (all specialties)
- Urologist
Configurable list*
In the last two (2) years, were you prescribed or did you refill a prescription that you will need to take for more than thirty (30) consecutive days?*

YesNo
Explain, for what condition, when was diagnosis, medication/treatment, any exams/tests, off work or disabled, hospitalized, are you fully recovered?*
In the last five (5) years, have you consulted or been treated for any mental illness (e.g.: depression, anxiety, personality disorder, suicide attempt, stress, insomnia)?*

YesNo
Write condition details?*
Do you suffer from or have you ever been diagnosed with a disorder or disease of the nervous system or a neurological condition?(Please refer to the list below.)*

YesNo
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 syndrome)
Multiple sclerosis
Parkinson’s disease
Describe condition?*
In the past five (5) years, have you consulted or been treated for muscle and bones disorders (e.g.: arthritis, tendinitis, fracture, back pain)?*

YesNo
If yes, please list all disorders and answer the questions as indicated: 1. Musculoskeletal disorder 2. Have you had any relapses in the past two (2) years or is it still currently present? 3. Have you fully recovered from thisdisorder for at least 12 months?*
Do you suffer from or have you ever been diagnosed with one of the following diseases or disorders?*

YesNo
Conditions:

Aneurysm
Any heart or blood vessel disorder
Any type 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 disease
Herniated disc
HIV/AIDS
Malformation(s) and/or congenital diseases
Sleep apnea
Temporary loss of vision or blindness
Transient ischemic attack (TIA)
Tumor, cyst, nodule, mass, fibroma or polyp
Describe the condition, date of diagnosis etc.*
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?*

YesNo
If yes, please provide as much detail as possible. (For example: nature of symptoms, reason for disability, name of recommended tests)*
Name and address of the physician following you for the disease(s) or disorder(s) you disclosed:*
Date of your last consultation?*

MonthDayYear
Date
For this question, you do not have to declare any test that is performed as part of a governmental screening program.In the last three (3) years, have you undergone any diagnostic test including: ultrasound, resting or stress electrocardiogram (ECG),CT scan, magnetic resonance imaging (MRI), biopsy, mammogram, colonoscopy, colposcopy, etc.?*

YesNo
If yes, please list all exams, reason, date, where was it done?*
Height (ft or cm)*
Weight (lb or kg)*
In the last year, have you lost more than 10 lb/5 kg (excluding weight loss following childbirth)?*

YesNo
How much weight?*
In the next two (2) years, do you plan to travel or reside outside of Canada or the United States? (Answer YES only if the total duration of your travel equals or exceeds 9 weeks.)*

YesNo
List details of Travel:*
In the past year, have you practiced aviation (other than as a passenger), scuba diving, parachuting, heli-skiing, a winter sport in areas at risk for avalanches, hang gliding, paragliding, mountaineering, climbing, combat sport, car or motorcycle racing, or do you plan to do so in the next year?*

YesNo
Which sport, frequency?*
Within the last five (5) years, has your driver’s licence been suspended or revoked (excluding due to unpaid fines)?*

YesNo
Within the last three (3) years, have you had four (4) or more driving violations (excluding parking tickets)?*

YesNo
In the last ten (10) years, have you been incarcerated, charged or convicted for any criminal offence?*

YesNo
On average, do you consume more than twelve (12) alcoholic beverages per week?(One consumption = 1 bottle of beer or 1 glass of wine or 1 ounce of liquor)*

YesNo
On average, in the past year, have you used marijuana, cannabis or hashish more than once in the same week?*

YesNo
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.)*

YesNo
Have you ever been treated for alcohol or drug use, been a member of a support group or been advised to reduce your consumption or to receive treatment for it?*

YesNo
If answer to any of above was Yes, Write Details below:*
Do you have a family doctor or a regular health care facility?*

YesNo
Name and address:*
What was the date of your last consultation?*

MonthDayYear
Date
Does your family doctor or regular health care facility possess medical information pertaining to the declared conditions?*

YesNo
If not, please indicate the physician and/or the health care facility holding the medical information for each of these conditions:*
Condition or reason, Name of the physician or the health care facility, Address, Date of last consultation
Politically Exposed Person (PEP)/ Heads of International Organizations (HIO): Please indicate if you, a member of your family (your spouse or common-law partner, your child, your mother or father, the mother or father of your spouse or common-law partner, or a child of your mother or father), or a close associate is a head of state or government; a member of the executive council of government or member of a legislature;a deputy minister (or equivalent); an ambassador or an ambassador’s attache or counsellor; a military general (or higher rank); a president of a state-owned company or bank; ahead of a government agency; a judge; a leader or president of a political party in a legislature; the head of an international organization established by the government of states; or the head of an institution established by an international organization.

YesNo
Are you a tax resident of Canada?*

YesNo
Are you a tax resident or citizen of the United States?*

YesNo
Are you a tax resident in a jurisdiction other than Canada or the United States?*

YesNo
Any Other Health/Medical Conditions that you want to disclose?*
Link to Upload Documents
Is there any Investment account related to this application?*

YesNo
Please indicate the client's stated reason(s) for purchasing this policy. (Not all policies are suitable for all purposes)*

Short Term SavingsIncome CreationLegacy/Inheritance/Estate ProtectionRetirement/Long Term SavingsGiftMortgage/Debt InsuranceBusiness/Key Person Protection/Buy Sell AgreementIncome/Family ProtectionEducation PurposesOther
Guarantee Type:*

(75/75)(75/100)(100/100)
Source of Funds*

Salary or Earned IncomeBorrowed FundsApplicant/Owner SavingsBusiness IncomeGifted FundsSale of PropertyProceeds from Death Benefits or Estate
What other investments does the Policy Owner currently hold?*

BondsSegregated FundsStocksMutual FundsTerm Deposits/GICReal Estate & MortgagesOther
Plans Chosen*
Funds Chosen and Percentage, Or any Other Comments about Investment Account?*
Would you like add a successor annuitant?*

YesNo
If Yes, Write their Name, SIN, Date of Birth, Relationship*
Choose Investor Profile*

EquitableIA
Equitable Investor Profile (Download after filling)
IA Investor Profile (Download after filling)
Should be Empty:

Information Sheet

Health and Lifestyle Questions