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.
Analysis of your needs
Your
insurance
Legal questions
About you
Please ensure information is correct
PAYMENT BY CREDIT CARD
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.
Premiums for 1 year or 2 years, taxes included!
| Age | BASIC OPTION | MACCIMUM OPTION | ||||||
| 1 YEAR | 2 YEARS |
1 YEAR | 2 YEARS |
|||||
| Female | Male | Female | Male | Female | Male | Female | Male | |
| Age 15 days to 4 years | $5.75 | $6.75 | $11.00 | $12.00 | $11.50 | $13.50 | $22.00 | $24.00 |
| Ages 5 to 11 | $8.00 | $10.00 | $13.00 | $18.00 | $16.00 | $20.00 | $26.00 | $36.00 |
| Ages 12 to 17 | $11.00 | $18.00 | $20.00 | $32.00 | $22.00 | $36.00 | $40.00 | $64.00 |
| Ages 18 to 24 | $16.00 | $30.00 | $29.00 | $54.00 | $32.00 | $60.00 | $58.00 | $108.00 |
| Ages 25 to 75 | $24.00 | $30.00 | $36.00 | $54.00 | $40.00 | $60.00 | $72.00 | $108.00 |
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.