Insurance application

  • I believe that I now have all the information I need to subscribe an Accifamily accident insurance policy and do not want help from an advisor.
  • I want to subscribe an Accifamily accident insurance policy for the individuals listed in the “Person to be insured” section.
  • I confirm that I have read the description of the applicable benefits and exclusions.

Personal information

  • I authorize Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”) to collect my personal information and share it for the purposes of reviewing my insurance application, and establishing and administering my contract, including the processing of any claims.
  • This authorization is also valid for the collection, use and communication of personal information concerning my minor children, insofar as they are included in my application.
  • I also authorize iA Financial Group, its affiliates and their agents to 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 send a written request to: iA Financial Group, Policyowner Services, 1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec City, QC G1K 7M3.)

Important information

  • Accifamily accident insurance can be cancelled if you make a false statement in your insurance application.
  • When the contract expires, iA Financial Group agrees to automatically renew the contract for a period of the same length, unless you indicate otherwise or your credit card has expired. By choosing to pay by credit card, your insurance coverage will not be interrupted and you will not have to send us any documents—we do it all for you! You will receive your renewal notice within the 30 days before your contract expires. The notice will indicate the new premium and the date it will be deducted. The premium at renewal may differ from the initial premium.

Information about the insurer and the firm (Quebec only)

Industrial Alliance Insurance and Financial Services Inc. is the insurer and firm selling Accifamily accident insurance.

Name and contact information of the insurer and the firm:

Industrial Alliance Insurance and Financial Services Inc.
1080 Grande Allée West
PO Box 1907, Station Terminus
Quebec City, QC G1K 7M3
1-800-463-6236

The firm is registered with the Autorité des marchés financiers in the following areas:

Insurance of persons
Group insurance of persons
Claims adjustment
Financial planning

Autorité des marchés financiers registration number 505873

Refer to the register of individuals and firms authorized to practise.

Enrol to Accifamily

Analysis of your needs

Your
insurance

Legal questions

About you

Please ensure information is correct

PAYMENT BY CREDIT CARD

Here are a few scenarios to help you assess your goals and needs.

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BASIC coverage

  • Anytime, anywhere accident coverage
  • No questionnaires or medical exam*
  • Quick and easy enrolment
  • Save with 2-year coverage
  • A single payment for the entire term of the coverage
  • See benefits and exclusions

* Applicable for new coverage only.

MACCIMUM coverage

  • All the same competitive benefits as the Basic coverage

+
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Basic requirement

Person to be insured

MM-DD-YYYY

Your personal information

E.g.: 1-234 Main Street, Toronto, ON
Address

Do you already have an iA Financial Group advisor?
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Analysis of your needs

You or a member of your family suffers a dismemberment, loss of use of a limb or a fracture as a result of an accident. Will your financial position allow you to take on unexpected expenses or compensate for the loss of income due to an absence from work caused by this situation?

You or a member of your family has an accident. Will you be able to pay any expenses that may result from this accident, such as professional fees?

And if the accident were to take place outside your province of residence, would you be able to pay the following expenses:

  • ambulance transport
  • doctor fees
  • hospital care (nursing, lab tests, X-rays or other tests)

As the result of an accident, you or a family member who is a full-time student becomes totally disabled. Will you be able to maintain your current standard of living in the short term?

And be able to cover the cost of job retraining or remedial classes?

In the event of natural (non-accidental) death of a child in your family or of a family member, would you be able to absorb the loss of income due to an absence from work or cover the funeral expenses related to this death?

Based on your answers, we encourage you to contact an advisor to discuss your financial goals and assess your insurance needs.

Your
insurance

Type

Type

Legal questions

Basic requirement

Are you planning on cancelling another insurance policy currently in effect now that you are enrolling in Accifamily?

Person to be insured

First name

Last name

Does the person to be insured reside permanently in Canada?

Gender

Date of birth

Name of educational institution

Premium

About you

Your personal information

First name

Last name

Email address

Primary phone number

Secondary telephone

Address

Do you already have an iA Financial Group advisor?

nom-votre-conseiller-libelle

Your advisor's code

Total premium:  

Insure four or more people under the same policy and get a 10% discount.

Single payment for the entire coverage period

Consult the conract (PDF)

Credit card information

Missing or invalid credit card number.
Missing or invalid credit card number.
Missing or Invalid expiry date.
Missing or invalid CCV/CVD code.
A problem occurred during the transaction. Sorry for any inconvenience this may have caused. Please contact our customer service at 1-888-266-2224.

Consent

I consent to the credit card information ending with being retained and used for payment of this present contract.

This consent is valid as long as the contract remains in force. In case of any changes to the present consent, the cardholder will be notified in writing.

Your consent is required to complete your enrolment.

Refuse Confirm refusal

Attention!

You will need to contact a financial security advisor to complete your enrolment in Accifamily and for further advice.

Attention!

This person is not eligible!
Only persons residing permanently in Canada are eligible for Accifamily accident insurance.

Attention!

Based on your answers, Accifamily may be the right solution for your goals and needs. We encourage you to continue with the enrolment to learn more about Accifamily’s different coverages and exclusions.

Attention!

Based on your answers, we encourage you to contact an advisor to discuss your financial goals and assess your insurance needs.

Customer Service

Monday to Friday: 8:30 am to 4:30 pm (Eastern Time)

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