iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
1-844-442-4636
Policy no.
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29. INTERIM INSURANCE AGREEMENT IN CASE OF DEATH OR CRITICAL ILLNESS
The interim insurance coverage applies to each proposed insured whose name appears on the application
bearing the same number as this agreement, according to the conditions hereunder.
Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”) offers insurance coverage as
of the date the application bearing the same number as this agreement is signed, when an amount equal to
1/12 of the annual premium is paid with the application, including any payment made upon enrolment in the
PAC/PAD plan. The amount paid will be applied to pay for the policy on the policy issue date.
Life insurance, accidental death, accidental fracture and critical illness coverage requested on the application
are payable according to the terms and exclusions of the underwritten policy and the conditions and
exclusions hereunder.
MAXIMUM AMOUNT OF INSURANCE
The maximum coverage for all interim insurance coverages in-force for all applications signed for the same
proposed insured is $500,000 including accidental death coverage.
Policy replacement
If the requested insurance replaces a contract of iA Financial Group whose face amount is lower than the face
amount of the requested insurance, the amount of the interim insurance is the difference between the requested
face amount on the application and the face amount of the replaced contract.
If the requested insurance replaces a contract of iA Financial Group whose face amount is greater than or equal
to the face amount of the requested insurance, no amount is payable under this interim insurance agreement.
CONDITIONS AND SPECIFIC EXCLUSIONS
This agreement does not include any disability benefits, any hospitalization riders, any paramedical care riders
or any changes of insurability that occur before the date the application is accepted other than if death has occurred
or a critical illness has been diagnosed.
The interim insurance agreement is null and void if any of the following cases apply:
• If, at the time the application is signed, the proposed insured had consulted or been treated for the
illness which caused his/her death or which led to the diagnosis of a critical illness;
• If the proposed insured had consulted a physician in the 30-day period before the application was signed
for a reason other than pregnancy;
• If any answer given on the application, the medical examination report or any other document or process
used to collect information with regards to the risk is incomplete or false and if a true answer had been
given, the application would not have been accepted as requested;
• If the proposed insured is less than 15 days old or more than 71 years old on the nearest birthday when
the application is signed;
• Specifically for the life insurance coverage, if the proposed insured commits suicide, or dies:
- while committing or attempting to commit a criminal offence;
- after using drugs or medication otherwise than prescribed by a physician;
- while he/she is driving a vehicle with a blood alcohol level higher than 80 milligrams per
100 millilitres of blood;
• Specifically for the critical illness coverage, if the proposed insured has already suffered from a covered
critical illness or if the diagnosis of a critical illness is cancer or if he/she self-inflicts injuries or he/she
does not survive 30 days after the date of the diagnosis.
The death benefit for the Home Protection Plan is not payable if the critical illness benefit is payable.
TERMINATION OF THE INTERIM INSURANCE AGREEMENT
The interim insurance agreement terminates on the date that the first of the following events occurs:
• The application is accepted without modification;
• 60 days after the application has been accepted with a modification such as a change of class, an extra
premium, a rate change or a change in the insurance amount;
• The acceptance by the applicant of a policy issued with a modification;
• The application is denied by iA Financial Group, regardless of whether or not the applicant has
been advised;
• The cancellation of the application by the applicant;
• In all cases, even though the 60-day period mentioned above has not expired, 90 days after the date
the application was signed.
The death benefit and critical illness benefit are payable according to the designated beneficiaries on the
application and the accidental fracture benefit is payable to the applicant.
Detach and submit to client
In order to consider your request for insurance, it is possible that we may request additional information.
A representative from an inspection company may contact you to obtain information concerning your
personal and financial status. A doctor or registered nurse from a paramedical organization may be
asked to complete a medical examination and/or collect a blood or urine sample. The analysis will be
used to determine the presence of different anomalies such as cholesterol, diabetes, hepatic disorders
or the use of medication, drugs, nicotine, and infection by the AIDS virus.
Before collecting this blood or urine specimen, your written consent will be required.
PRE-NOTICE FROM MIB INC.
CONSTITUTION OF A FILE AND PROTECTION OF PERSONAL INFORMATION
NOTICE DISCLOSURE STATEMENT
Information regarding your insurability will be treated as confidential. iA Financial Group and
its reinsurers may, however, make a brief report thereon to MIB INC., a non-profit membership
organization of life insurance companies, which operates an information exchange on behalf of its
members. If you apply to another MIB INC. member company for life or health coverage, or a claim for
benefits is submitted to such company, the MIB INC., upon request, will supply such company with the
information it may have in its files.
Upon receipt of a request from you, the MIB INC. will arrange disclosure of any information it may
have in your file. If you question the accuracy of information in the MIB INC.’s file, you may contact
them and request a correction. The address of the MIB INC.’s information office is: MIB INC.,
330 University Avenue, Suite 501, Toronto, Canada, M5G 1R7; telephone: 416 597-0590. Information
about the MIB INC. may be obtained on its website at www.mib.com.
iA Financial Group may also release information in its file to other life insurance companies to whom
you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
In order to ensure the confidentiality of your personal information, iA Financial Group will
establish a file, the object of which is to offer you insurance, annuity and credit products and other
complementary services according to your needs, and in which the necessary information gathered
for this object will be kept.
Only the employees or representatives of iA Financial Group who need this information as part of their
duties, or any other person whom you authorize, will have access to this file. Your file will be kept at
iA Financial Group’s offices.
You are entitled to access the personal information contained in this file and, if necessary, to have it
rectified by sending a written request to the following address:
Industrial Alliance
Insurance and Financial Services Inc.
Chief Privacy Officer
1080 Grande Allée West
PO Box 1907, Station Terminus
Quebec City, QC G1K 7M3
iA Financial Group may establish a list of its clients for its own commercial prospecting purposes or
that of member companies of the iA Group. However, you are entitled to have your name removed
from this list by making a written request to this effect to the Information Access Officer or Privacy
Officer at the addresses indicated above.
• INTERIM INSURANCE AGREEMENT IN CASE
OF DEATH OR CRITICAL ILLNESS
F4A-18
June 2020
F4A-18(20-06)
Signed at Province this day of
20
Agent’s signature
This application is being submitted by an authorized representative of iA Financial Group who will
receive compensation if the application is accepted and in no way imposes on the applicant an
obligation to transact additional business with said representative.
