IA - YAM Life Insurance

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Step 1 of 30 - Identification

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Product Code

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Term Coverage

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Coverage Amount

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Monthly Premium

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perm.term.iamnotsure

Term

Permanent

I'm not sure

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Sex

Identification

Last Name*

First Name*

Middle name

If your name has changed, what was your full name at birth?

Language*

English

French

Gender*

Male

Female

Gender*

Male

Female

Date of birth*

Year

Month

Day

Social Insurance Number

Relationship to applicant*

For Universal Life and iA PAR policies only (to be completed only if the insured is also the applicant)

Main occupation (Be specific, terms such as “manager” are not sufficient):*

Name of employer:*

Main occupation (Be specific, terms such as “manager” are not sufficient):

Name of employer:

Address

Always mandatory (If it is not possible to provide a street address, please provide a copy of an identification document with proof of address.)

Address*

City*

Postal code*

Province*

Station

Rural route

P.O. Box

Contact

Home phone

Cell phone *

Phone Number*

Work Phone

Extension

Email Address*

Confirmation of identity

For Universal Life and iA PAR policies only. To be completed only if the insured is also the applicant. Refer to an authentic and unexpired piece of government-issued PHOTO identification.

Type of document*

Document number*

Place of issue*

Expiry date (if applicable)

Year

Month

Day

Type of document

Document number

Place of issue

Expiry date (if applicable)

Year

Month

Day

Pending insurance

Do you have other pending insurance applications?*

Yes

If YES, considering all your pending insurance applications with all insurance companies (including iA Financial Group), what is the total amount you plan on buying?

Main insured

Amount of life insurance*

Amount of critical illness insurance*

Amount of disability insurance*

Declined insurance

Have you ever been declined for insurance?*

Yes

If YES, please provide the following information:

Main insured

Year*

Reason(s)*

Check if it applies

Life

Critical illness

Disability

@1- add another declined insurance

add another

Year

Reason(s)

Check if it applies

Life

Critical illness

Disability

@2- add another declined insurance

add another

Year

Reason(s)

Check if it applies

Life

Critical illness

Disability

Insurance in force

Do you have in-force insurance on your life, excluding group insurance or credit insurance?*

Yes

If YES, please provide the following information:

Main insured

Name of company*

Surrender of contract?*

Yes

Policy number (iA contract)*

Amount of Life insurance

Amount of critical illness insurance

Amount of disability insurance

Year of issue*

Need*

Personal

Business

@ 1- add another insurance in force

add another

Name of company

Surrender of contract?

Yes

Policy number (iA contract)

Amount of Life insurance

Amount of critical illness insurance

Amount of disability insurance

Year of issue

Need

Personal

Business

@ 2- add another insurance in force

add another

Name of company

Surrender of contract?

Yes

Policy number (iA contract)

Amount of Life insurance

Amount of critical illness insurance

Amount of disability insurance

Year of issue

Need

Personal

Business

APPLICANT

For individual insurance, the main insured is the applicant, unless otherwise indicated below.

For joint insurance, all joint insureds are applicants, unless otherwise indicated below.

For a Multilife application, please specify the applicant (in the absence of any indication, the main insured is by default considered applicant).

Please specify the applicant:*

Main insured

Additional insured

Other

Identification

(For corporations, please indicate the organization’s name and the place of incorporation.)

Last name*

First name*

Middle name

Sex*

Male

Female

Date of birth*

Year

Month

Day

Age*

Social Insurance Number

For Universal Life and iA PAR policies only.

If the applicant is an individual: Main occupation

Name of employer:*

Name of employer:

If the applicant is an organization: Business sector (Be specific):

Address

Always mandatory (If it is not possible to provide a street address, please provide a copy of an identification document with proof of address.)

same address ?

Same address as the Main Insured

Address*

City*

Province*

Postal code*

Station

Rural route

P.O. Box

Contact

Same contact ?

Same contact as the Main Insured

Home phone

Cell phone*

Work phone

Extension

Email*

Confirmation of identity

For Universal Life and iA PAR policies only. Refer to an authentic and unexpired piece of government-issued PHOTO identification.

confirmation identity same info ?

Same as Main Insured

Type of document*

Document Number*

Place of issue*

Expiry Date (if applicable)

Year

Month

Day

Type of document

Document Number

Place of issue

Expiry Date (if applicable)

Year

Month

Day

Contingent owner

Last name*

First name*

Sex*

Male

Female

Date of birth*

Year

Month

Day

REGULATORY QUESTIONS

PREMIUM FINANCING – ALWAYS MANDATORY

Will the life insurance premiums be financed and/or paid by a lender or any other person who has no relationship with the insured person?*

Yes

If YES, indicate the name of the lender or the other person:*

Is the applicant an Individual or an Organization?*

Individual

Organization

FOR INDIVIDUAL APPLICANTS

TAXATION - ALWAYS MANDATORY

Is one of the applicants a U.S. citizen or a U.S. resident for U.S. tax purposes?*

Yes

If YES, specify the name and the taxpayer identification number (TIN) or SSN of the applicant(s).

Name*

TIN or SSN*

Name

TIN or SSN

Is one of the applicants a tax resident in a jurisdiction other than Canada or the United States?*

Yes

If YES, specify the name, the jurisdiction(s) of tax residence and taxpayer identification number(s) (TIN) of the applicant(s).

Name*

Jurisdiction*

TIN*

Name

Jurisdiction

TIN

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Permanent Life Coverage*

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T10 R & C*

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T20 R & C*

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Pick-A-Term T25*

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Pick-A-Term T30*

ANTI-MONEY LAUNDERING - FOR UNIVERSAL LIFE AND iA PAR POLICIES ONLY

Is the applicant acting on the instructions of an undisclosed individual or organization (a third party)?*

Yes

A third party includes, but is not limited to, the following:

a person contributing funds to this contract who is not the applicant/owner
an attorney appointed under a power of attorney
an undisclosed individual or organization that is instructing the applicant/owner

If YES, the instructions are provided by (provide name):*

Third party type*

An individual

A corporation

Another type of organization

Date of birth:*

Year

Month

Day

Incorporation number:*

Place of incorporation:*

Please specify:*

Relationship to applicant:*

Address:*

Telephone number:*

Occupation / Type of business (be specific):*

What is the source of funds used to pay the premiums of this insurance?*

Employment income/salary

Retirement income/pension

Business income

Investments

Savings

Loan

Inheritance

Other

Provide details:*

Will a lump-sum payment of $100,000 or more be made on this policy?*

Yes

If YES, please complete form F51-208A-1 and submit it with the F1A application form.

TAXATION - ALWAYS MANDATORY

Is the applicant a corporation or partnership organized in the U.S. or a U.S. state?*

Yes

If YES, please provide your employer identification number (EIN):

Employer Identification Number (EIN)*

Does any individual directly or indirectly own or control 25% or more of the organization that will own this policy?*

Yes

If YES, is one of these individuals:*

A U.S. citizen or a U.S. resident for U.S. tax purposes

A tax resident in a jurisdiction other than Canada or the United States

Neither of the above

If NO, is the senior official of the organization:*

A U.S. citizen or a U.S. resident for U.S. tax purposes

A tax resident in a jurisdiction other than Canada or the United States

Neither of the above

Please complete form F51-208A-3 and submit it with the F1A application form.

ANTI-MONEY LAUNDERING - FOR UNIVERSAL LIFE AND iA PAR POLICIES ONLY

Is the applicant acting on the instructions of an undisclosed individual or organization (a third party)?*

Yes

A third party includes, but is not limited to, the following:

a person contributing funds to this contract who is not the applicant/owner
an attorney appointed under a power of attorney
an undisclosed individual or organization that is instructing the applicant/owner

If YES, the instructions are provided by (provide name):*

Third party type*

An individual

A corporation

Another type of organization

Date of birth:*

Year

Month

Day

Will a lump-sum payment of $100,000 or more be made on this policy by this third party?*

Yes

If YES, please complete form F51-208A-1 (in the third party's name) and submit it with the F1A application form.

Incorporation number:*

Place of incorporation:*

Please specify:*

Relationship to applicant:*

Address:*

Telephone number:*

Occupation / Type of business (be specific):*

What is the source of funds used to pay the premiums of this insurance?*

Business income

Investments

Loan

Other

Provide details:*

What is the type of organization?*

Corporation (legal entity or stock company whose members are shareholders)

Partnership (trade partnership and partnership whose members are partners)

Trust

Not-for-profit organization

Other

Be specific:*

Existence of the contracting organization

For corporations, a corporate search will be conducted by iA Financial Group to verify the corporation’s existence. For non-corporate organizations, please attach paper copies of documents verifying existence. (E.g.: For a partnership, a partnership agreement or a partnership registration; for a trust, the trust agreement or a document amending the trust.)

Please attach copies of documents that explain the ownership, control and structure of the organization and a recent document confirming the organization signatories. A chart should be attached for complex organizations.

Verify the identity of the individual(s) conducting the transaction on behalf of the organization. If there is more than one individual, verify the identity of each, up to a maximum of three.

Refer to an authentic and unexpired piece of government-issued photo identification. Cannot be a municipal identification document.

1. Name and title/position:*

Type of identification document:*

Document number:*

Expiry date (if applicable):

Year

Month

Day

Date identity confirmed:*

Year

Month

Day

Place of issue:*

2. Name and title/position:

Type of identification document:

Document number:

Expiry date (if applicable):

Year

Month

Day

Date identity confirmed:

Year

Month

Day

Place of issue:

3. Name and title/position:

Type of identification document:

Document number:

Expiry date (if applicable):

Year

Month

Day

Date identity confirmed:

Year

Month

Day

Place of issue:

Record the name and address of each individual who owns or controls, directly or indirectly, 25% or more of the shares of the corporation or 25% or more of the non-corporate organization.

Please tick this box If:

There is no individual who owns or controls, directly or indirectly, 25% or more of the shares of the corporation or 25% or more of the non-corporate organization

First name:*

Last name:*

Complete address (not only a P.O. Box)*

First name:

Last name:

Complete address (not only a P.O. Box)

First name:

Last name:

Complete address (not only a P.O. Box)

First name:

Last name:

Complete address (not only a P.O. Box)

Record the names of all directors of the board in the case of a corporation or in the case of any other type of organization that has a board of directors. Please attach a separate sheet of paper if needed.

First name:*

Last name:*

First name:

Last name:

First name:

Last name:

First name:

Last name:

In the case of a trust, record the names, dates of birth and addresses of all trustees, all known beneficiaries, and all settlors. Please attach a separate sheet of paper if needed. [Note: A settlor is an individual or organization who established the trust.]

First name:*

Last name:*

Date of birth:*

Year

Month

Day

Complete address (not only a P.O. Box)*

Type*

Trustee

Beneficiary

Settlor

First name:

Last name:

Date of birth:

Year

Month

Day

Complete address (not only a P.O. Box)

Type

Trustee

Beneficiary

Settlor

First name:

Last name:

Date of birth:

Year

Month

Day

Complete address (not only a P.O. Box)

Type

Trustee

Beneficiary

Settlor

First name:

Last name:

Date of birth:

Year

Month

Day

Complete address (not only a P.O. Box)

Type

Trustee

Beneficiary

Settlor

Is the applicant/owner a not-for-profit organization?*

Yes

If YES, please provide the following information:

Registered as a charity with the Canada Revenue Agency?*

Yes

Canada Revenue Agency registration number:*

Does the applicant/owner solicit charitable donations from the public?*

Yes

Cost of insurance

Cost of insurance leveling*

Annual (YRT)

Level only (with no Quick payment option)

Level – Quick payment option

Quick payment leveling*

10 years

15 years

20 years

EQUIBUILD

For EquiBuild, provide the current version of the complete illustration signed by the client and the information required under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations (page 5).

Base Coverage*

Cost type*

Level

15-year Payment

Integrated Coverage*

10 years

20 years

Integrated Coverage 10 years*

Integrated Coverage 20 years*

EQUIBUILD BONUS PAYMENT OPTIONS*

Paid-Up Additions (PUA) purchase

Deposit to the Accumulation Fund

EQUIBUILD BONUS PAYMENT OPTIONS*

Paid-Up Additions (PUA) purchase

BENEFICIARY – LIFE INSURANCE

The lack of designation constitutes a revocable designation in favour of the applicant (in equal parts if more than one applicant), if different from the insured. Do not designate a beneficiary for child module or module PLUS coverage.

How many beneficiaries do you have?*

Beneficiary 1

Last name*

First name*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

How many contingent beneficiaries do you have?*

Contingent beneficiary 1 (last name, first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

Contingent beneficiary 2 (last name, first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

* Total % share must equal 100% for Contingent Beneficiaries for Primary Beneficiary 1

Beneficiary 2

Last name*

First name*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

How many contingent beneficiaries do you have?*

Contingent beneficiary 1 (last name , first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

Contingent beneficiary 2 (last name, first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

* Total % share must equal 100% for Contingent Beneficiaries for Primary Beneficiary 2

Beneficiary 3

Last name*

First name*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

* Total % share must equal 100% for Primary Beneficiaries.

Relationship to proposed insured*

Please enter a number from 0 to 100.

How many contingent beneficiaries do you have?*

Contingent beneficiary 1 (last name , first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

Contingent beneficiary 2 (last name , first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

* Total % share must equal 100% for Contingent Beneficiaries for Primary Beneficiary 3

BENEFICIARY OF THE FUNDS – UNIVERSAL LIFE POLICIES

The lack of designation constitutes a revocable designation in favour of the beneficiary or beneficiaries named in the “Beneficiary – Life Insurance” section above.

Type

Applicant(s) - in equal parts if applicable

Beneficiary of insured

Other

Beneficiary

Last name

First name

Sex

Male

Female

Type

Revocable

Irrevocable

Date of birth

Year

Month

Day

Relationship to proposed insured

Please enter a number from 0 to 100.

How many contingent beneficiaries do you have?

Contingent beneficiary 1 (last name, first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

Contingent beneficiary 2 (last name, first name)*

Sex*

Male

Female

Type*

Revocable

Irrevocable

Date of birth*

Year

Month

Day

Relationship to proposed insured*

Please enter a number from 0 to 100.

* Total % share must equal 100% for Contingent Beneficiaries

RISK CLASS FOR TERM LIFE CONTRACTS OR RIDERS FOR $2,000,001 OR MORE

If preferred underwriting can be granted:

Reduce the premium

Increase the face amount

ELIGIBILITY

Tobacco use

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.)?*

Never

In the past year

Between 1 and 3 years ago

Between 3 and 5 years ago

More than 5 years ago

Specify Your Tobacco Use:

Cigarettes*

Yes

Cigarillos*

Yes

Electronic cigarettes*

Yes

Gum or nicotine patches*

Yes

Cigars*

Yes

Specify how many cigars you have smoked in the past 12 months:*

Marijuana/cannabis mixed with tobacco*

Yes

Other tobacco or nicotine products (chewing tobacco or snuff, betel nuts, shisha, hookah/water pipe, etc.)*

Yes

Legal status

Were you born in Canada?*

Yes

What is your country of birth?*

Have you lived in Canada for at least three years?

Have you lived in Canada for at least three years?*

Yes

Have you lived in Canada for at least one year?

Have you lived in Canada for at least one year?*

Yes

What is your legal status?*

Permanent resident

Canadian citizen

Work permit (other than seasonal worker)

Officially accepted Convention refugee

Other

Legal status*

In order to reduce delays in processing your application, you may provide your social insurance number (SIN) in section 1.

Education, occupation, income and net worth

Highest level of education completed:*

No diploma

High school or equivalent

Apprenticeship Program

College

Undergraduate Certificate

Bachelor’s Degree

Postgraduate Degree

Employment (Occupation):*

Employer (name of the business):*

Sector of occupation:*

Military

Construction

Marine transportation (outside Canada)

Natural resources (forestry, mining, oil or gas industry)

Arts and entertainment (music, cinema, circus, etc.)

Professional sport (athlete)

Unemployed

Disabled

None of the above

Income and net worth

Annual income before taxes:*

Canadian Net Worth (assets – liabilities):*

Foreign Net Worth in canadian dollars (CAD):

Investment Holdings:

Value*

Minus Liabilities*

Net Value*

Bank Holdings:

Value*

Minus Liabilities*

Net Value*

Canadian Tax Return (T1 plus T1135):

Value*

Minus Liabilities*

Net Value*

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Insurance need

Personal

PREDECLARATIONS

(In order to reduce delays in processing the application, please complete this section.)

Have you sought medical attention or received treatment for or been told you have symptoms of any of the following diseases or disorders?*

Cerebral vascular accident/stroke (CVA)/Transient ischemic attack (TIA)

Angina /Heart attack (with or without bypass surgery/angioplasty)

Cancer /Malignant tumor (any site)

Major depression (in the last five years) or Bipolar disorder (any duration)

Diabetes

Hepatitis B or C (other than carrier)

Crohn’s disease /Ulcerative colitis diagnosed in the last 8 years

Chronic obstructive pulmonary disease (COPD) / Emphysema

Rheumatoid arthritis polyarthritis/Spondylarthritis

Please provide details for each disease or disorder indicated.

Disease or disorder*

Date of diagnosis*

Year

Month

Day

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date*

Have you been hospitalized or did you undergo a surgery?*

Yes

Specify the date*

Year

Month

Day

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Specify the date*

Disease or disorder

Date of diagnosis

Year

Month

Day

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Date of diagnosis*

Have you been hospitalized or did you undergo a surgery?

Yes

Specify the date

Year

Month

Day

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Specify the date

Were you on disability?*

Yes

From:*

Year

Month

Day

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From:*

to:

Year

Month

Day

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to:*

Full name and address of the doctor(s) following you for the disease(s) or disorder(s) you disclosed:*

Full name and address of the doctor(s) following you for the disease(s) or disorder(s) you disclosed:

DECLARATIONS OF INSURABILITY

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	Cosmetic surgery without complications	Pregnancy, delivery or miscarriage without complications
Adenoid removal	Hemorrhoids	Allergies
Menopause	Tonsil removal	Contraceptives
Otitis	Vision impairment corrected with glasses or contact lenses

A - Family history

Has any member of your family (father, mother, brother, sister) suffered from one of the following conditions before the age of 65?

Has any member of your family (father, mother, brother, sister) suffered from one of the following conditions before the age of 65?*

Yes

You are not required to disclose a family history of hypertension, high cholesterol or depression.

Please indicate the condition

Cancer

Multiple sclerosis

Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)

Polycystic kidney disease

Death from an unknown cause

Cardiovascular disease (e.g.: CVD, myocardial infarction)

Parkinson’s disease

Neurological disease (excluding epilepsy)

Hemophilia

Diabetes

Alzheimer’s disease

Huntington’s chorea

Any other hereditary disorder

I don’t know since I was adopted or I have no contact with my family

Specify hereditary disorder*

Relationship*

Please specify disease*

Approximate age at diagnosis*

Relationship

Please specify disease

Approximate age at diagnosis

Relationship

Please specify disease

Approximate age at diagnosis

B - Specialists and medication

1) In the last five (5) years, have you consulted a specialist? (Please refer to the list below.)*

Yes

Cardiologist	Gynecologist	Neurologist	Psychiatrist
Dermatologist	Hematologist	Oncologist	Radiologist
Endocrinologist	Internist (Internal medicine)	Ophthalmologist	Rheumatologist
Gastroenterologist	Neonatologist	Otorhinolaryngologist (ENT)	Surgeon (all specialties)
Geriatrician	Nephrologist	Pneumologist	Urologist

1.Physician’s specialty*

2.Was this consultation for a follow-up of a pre-existing condition?*

Yes

Name of the condition*

3.Was a diagnosis made?*

Yes

My diagnosis is:*

4.Did you undergo exams or tests in connection with this consultation?*

Yes

1. Physician’s specialty

2. Was this consultation for a follow-up of a pre-existing condition?

Yes

Name of the condition

3. Was a diagnosis made?

Yes

My diagnosis is:

4. Did you undergo exams or tests in connection with this consultation?

Yes

1. Physician’s specialty

2. Was this consultation for a follow-up of a pre-existing condition?

Yes

Name of the condition

3. Was a diagnosis made?

Yes

My diagnosis is:

4. Did you undergo exams or tests in connection with this consultation?

Yes

2) 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?*

Yes

Please list each related MEDICAL CONDITION
If needed, refer to the medical conditions and questionnaires table attached to this application.
Please contact your YAM Insurance representative for a copy of the questionnaire.

MEDICAL CONDITION 1.*

MEDICAL CONDITION 2.

C - Neurological and mental health

1) 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) *

1) In the last five (5) years, have you consulted or been treated for any mental illness?*

Yes

Please list the conditions:

Condition 1.*

Condition 2.

2) Do you suffer from or have you ever been diagnosed with a disorder or disease of the nervous system or a neurological condition?*

Yes

Please select all applicable conditions*

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

Other

Specify the Condition:*

D - General medical conditions

1) In the past five (5) years, have you consulted or been treated for muscle and bones disorders (e.g.: arthritis, tendinitis, fracture, back pain)? *

1) In the past five (5) years, have you consulted or been treated for muscle and bones disorders (e.g.: arthritis, tendinitis, fracture, back pain)?*

Yes

Please list all disorders and answer the questions as indicated.

Musculoskeletal disorder*

Have you had any relapses in the past two (2) years or is it still currently present?*

Yes

Have you fully recovered from this disorder for at least 12 months?*

Yes

Musculoskeletal disorder

Have you had any relapses in the past two (2) years or is it still currently present?*

Yes

Have you fully recovered from this disorder for at least 12 months?*

Yes

Musculoskeletal disorder

Have you had any relapses in the past two (2) years or is it still currently present?*

Yes

Have you fully recovered from this disorder for at least 12 months?*

Yes

2) Do you suffer from or have you ever been diagnosed with one of the following diseases or disorders?*

Yes

Please select all applicable 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

E - Investigation and build

1) 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?*

Yes

Please provide as much detail as possible.*

Please provide as much detail as possible.

Name and address of the physician following you for the disease(s) or disorder(s) you disclosed:*

Date of your last consultation:*

Year

Month

Day

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Date of your last consultation:*

For this question, you do not have to declare any test that is performed as part of a governmental screening program.

2) 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.? *
If needed, refer to the medical conditions and questionnaires table attached to this application.

2) 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.?*

Yes

Please list all exams.

Exam 1:*

Exam 2:

Exam 3:

3) Height and weight

Height:*

Type*

Weight:*

Type*

In the last year, have you lost more than 10 lb/5 kg (excluding weight loss following childbirth) ?*

Yes

How much weight have you lost?*

Type*

F - Travels, COVID-19 and sports

1) Foreign travels

In the next two (2) years, do you plan to travel or reside outside of Canada or the United States for a duration of 9 weeks or more?

In the next two (2) years, do you plan to travel or reside outside of Canada or the United States for duration of 9 weeks or more?

Yes

2) COVID-19

a. In the last 4 weeks, have you traveled outside of Canada, or have you transited through an airport?

a. In the last 4 weeks, have you travelled outside of Canada or have you transited through an airport?

Yes

Specify the Places you visited and/or transited through and date of return:

Asia

Africa

Europe

Oceania

North America

South America

Date of return from Asia:*

Year

Month

Day

Date of return from Africa:*

Year

Month

Day

Date of return from Europe:*

Year

Month

Day

Date of return from Oceania:*

Year

Month

Day

Date of return from North America:*

Year

Month

Day

Date of return from South America:*

Year

Month

Day

b. Are you experiencing symptoms of fever, cough, or difficulty breathing?*

Yes

c. In the last 4 weeks, have you or someone close to you been in contact with a confirmed or suspected case of COVID-19 coronavirus infection? *

c. In the last 4 weeks, have you or someone close to you been in contact with a confirmed or suspected case of COVID-19 coronavirus infection?*

Yes

d. In the last 12 months, have you been hospitalized for the COVID-19 coronavirus disease? *

d. In the last 12 months, have you been hospitalized for the COVID-19 coronavirus disease?*

Yes

Date of hospitalization:*

Year

Month

Day

Indicate the full name and address of the physician or health care facility that can provide the complete information.

Name of the physician or health care facility:*

Address 1:*

Address 2:

3) Sports and aviation

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? *

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?*

Yes

Please select the sports practiced*

Automobile or motorcycle racing

Aviation (including hang gliding and paragliding)

Combat sport

Heli-skiing or winter sports in areas at risk for avalanches

Mountaineering or outdoor climbing

Parachuting other than with a tandem instructor

Scuba diving with exploration of wrecks, ice diving, cave diving, rescue diving or diving to a depth of more than 75 ft. (23 m)

I do not practice any of these sports as described

G - Life habits

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

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

Yes

Type of moving violation*

Date of violation*

Year

Month

Day

This field is hidden when viewing the form

Date of violation*

Type of moving violation

Date of violation*

Year

Month

Day

This field is hidden when viewing the form

Date of violation

Type of moving violation

Date of violation*

Year

Month

Day

This field is hidden when viewing the form

Date of violation

Please indicate the type of driving licence you have:*

Learner’s licence

Novice’s licence / Probationary licence

Regular driver’s licence

Other

please provide details about your driving licence*

Has your licence been reinstated?*

Yes

Please provide the date when your licence was reinstated:*

Year

Month

Day

This field is hidden when viewing the form

Please provide the date when your licence was reinstated:*

Did you drive while your licence was suspended (excluding driving with a restricted licence or with a vehicle equipped with an alcohol ignition interlock device)?*

Yes

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

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

Yes

Type of moving violation*

Date of violation*

Year

Month

Day

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Date of violation

Type of moving violation

Date of violation*

Year

Month

Day

This field is hidden when viewing the form

Date of violation

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

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

Yes

4) Do you consume more than twelve (12) alcoholic beverages per week?*

Yes

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

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

Yes

6) Within the last ten (10) years, have you used any drug other than marijuana, cannabis or hashish? *

6) Within the last ten (10) years, have you used any drug other than marijuana, cannabis or hashish?*

Yes

7) 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?*

Yes

for what reasons?*

Alcohol use

Drug use

H - Physicians and attending physician’s statements

1) Do you have a family doctor or a regular health care facility?*

Yes

please indicate the name and full address

Name:*

Full address:*

What was the date of your last consultation?*

Year

Month

Day

This field is hidden when viewing the form

What was the date of your last consultation?*

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

Yes

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*

Year

Month

Day

This field is hidden when viewing the form

Date of last consultation*

Condition or reason

Name of the physician or the health care facility*

Address*

Date of last consultation*

Year

Month

Day

This field is hidden when viewing the form

Date of last consultation

Condition or reason

Name of the physician or the health care facility*

Address*

Date of last consultation*

Year

Month

Day

This field is hidden when viewing the form

Date of last consultation

Condition or reason

Name of the physician or the health care facility*

Address*

Date of last consultation*

Year

Month

Day

This field is hidden when viewing the form

Date of last consultation

ADDITIONAL QUESTIONNAIRES

MEDICAL QUESTIONNAIRES:

Family history

Please indicate if, because of your family history of cancer, you have ever had tests such as:

- Mammogram:*

Yes

Date *

Untitled*

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Date*

Were the results normal?*

Yes

please provide details of your condition or situation :*

- Colonoscopy:*

Yes

Date *

Untitled*

This field is hidden when viewing the form

Date*

Were the results normal?*

Yes

Please provide details of your condition or situation:

Please provide more information regarding the family history for hereditary or neurological disease (e.g.: accurate diagnosis, date, treatments, medication, medical follow-up, complications, exams done, time off work, etc.):*

Please provide more information regarding the family history for hereditary or neurological disease accurate diagnosis, type of manifestation for the person affected, screening tests, results, name and address of physician seen, etc.):

Back disorders (Examples: Middle back pain, lower back injury, herniated disc, neck pain, etc.)

Declared disorder(s)

Please provide the location of pain or discomfort:

Cervical region (neck)

Thoracic region (middle of the back)

Lumbosacral region (lower back, including sciatic nerve)

Other

Specify:

Please identify the type of treatment received or to come:

Injection

Anti-inflammatory or muscle relaxant drugs

Medication derived from morphine, opiate or marijuana/cannabis*

Medication derived from methadone*

Marijuana/cannabis

Treatment with health professional (e.g.: physiotherapist, osteopath, etc.)

Past operation or surgery

Pending operation or surgery*

Other

No treatment

Specify:

Last time you experienced problems, had symptoms or had an episode

back disorder year

back disorder month

This field is hidden when viewing the form

Last time you experienced problems, had symptoms or had an episode

1. Please provide details of your treatment

2. Please provide details of your treatment

3. Please provide details of your treatment

Which of the following best describes the severity of your condition?

Mild - No limitation or restriction in activities of daily living. Few or no symptoms.

Moderate - Some limitations or restrictions in activities of daily living. Intermittent symptoms.

Severe - Several limitations or restrictions in activities of daily living. Persistent or chronic symptoms.

Please specify or clarify your condition (provide as much detail as possible):

How many days have you been off work (or absent from school) because of this condition in the last twelve (12) months?

How many distinct episodes have you suffered from with this condition in the past three (3) years?

Are your back issues caused by a herniated disc?

Yes

Please provide the frequency of the treatments and symptoms and the duration and dates of your disability and episodes where you have suffered from your condition:

Musculo-articular disorders (Examples: Dislocated elbow, ankle sprain, arthritis in knee, shoulder bursitis, capsulitis of shoulder, tendinitis, etc.)

Declared disorder(s)

Please provide the location of pain or discomfort including the side of the body

Please identify in the list below the type of treatment received or to come:

Injection

Anti-inflammatory or muscle relaxant drugs

Medication derived from morphine, opiate or marijuana/cannabis*

Medication derived from methadone

Marijuana/cannabis*

Treatment with health professional (e.g.: physiotherapist, osteopath, etc.)

Past operation or surgery

Pending operation or surgery

Other

No treatment

Specify:

Last time you experienced problems, had symptoms or had an episode

Untitled

This field is hidden when viewing the form

Last time you experienced problems, had symptoms or had an episode

1. Please provide details of your treatment

2. Please provide details of your treatment

3. Please provide details of your treatment

How many days have you been off work (or absent from school) because of this condition in the last twelve (12) months?

How many distinct episodes have you suffered from with this condition in the past three (3) years?

Has this condition required the installation of a prosthesis, orthesis or any other artificial hardware?

Yes

please provide more information regarding your treatment

Please provide the frequency of the treatments and symptoms and the duration and dates of your disability and episodes where you have suffered from your condition:

Mental health (Examples: Mood disorder, generalized anxiety disorder, depression, adjustment disorder, stress, psychosis, bipolar disorder, personality disorder, etc.)

Declared conditions

Please list every symptomatic episode for this condition:

a) Duration (days, weeks or months)*

Start date *

start year @1*

start month @1*

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Start date*

b) Duration (days, weeks or months)

Start date

start year @2

start month @2

This field is hidden when viewing the form

Start date

Have you been off work or disabled because of this condition?*

Yes

a) Duration (days, weeks or months)*

Start date *

start year @3*

start month @3*

This field is hidden when viewing the form

Start date*

b) Duration (days, weeks or months)

Start date

start year @4

start month @4

This field is hidden when viewing the form

Start date

What is the number of different medications that you are currently taking for this condition?*

Have you already taken medication for your condition?

Yes

What is the date of your last medication treatment? *

year of last medication*

month of last medication*

This field is hidden when viewing the form

What is the date of your last medication treatment?*

Have you ever been hospitalized or had inpatient therapy for this condition?*

Yes

Please provide more information about your hospitalization or therapy*

High blood pressure (Examples: HBP, hypertension, high blood pressure, elevated blood pressure, etc.)

1) Is your condition well controlled with no complication according to your physician?*

Yes

1. Please provide more information regarding the complications of your condition*

2. Please provide more information regarding the complications of your condition

3. Please provide more information regarding the complications of your condition

2) Are you currently being treated with medication for this condition?*

Yes

Please specify or clarify your condition (provide as much detail as possible):*

Please specify or clarify your condition (provide as much detail as possible):

Has your medication been changed in the last six months (addition/replacement of a medication or increase of dosage)?*

Yes

Asthma (Examples: Asthma attack, asthma bronchitis, allergic asthma, etc.)

1) How many times per week do you experience symptoms?

2) How many times per week do you take medication for your condition?

3) Have you taken oral steroid tablets (e.g.: Prednisone or Prednisolone) in the last twelve (12) months for this condition?

Yes

4) Have you been hospitalized within in the last twelve (12) months for this condition ?

Yes

5) How many days have you been off work (or absent from school) because of this condition in the last twelve (12) months?

Diabetes (Examples: Type 1 or 2 diabetes, diabetes mellitus, impaired glucose tolerance, gestational diabetes, etc.)

1) Which of the following currently represents your condition?*

Type 1 (juvenile or insulin-dependent diabetes)

Type 2 (noninsulin-dependent diabetes)

Gestational diabetes (current)

Gestational diabetes (prior history)

Past history of diabetes (other than pregnancy)

Impaired glucose intolerance or pre-diabetes

Unknown type diabetes

2) When was your diagnosis made?*

Year

Month

Day

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2) When was your diagnosis made?*

3) What is the type of treatment for your diabetes?*

Diet

Oral medication

Insulin

None

4) Are you currently pregnant?*

Yes

Are you currently more than 24 weeks pregnant?*

Yes

Has a licensed medical professional pronounced you fully recovered from this condition?*

Yes

Sleep apnea (Examples: Obstructive sleep apnea, apnea-hypopnea syndrome, etc.)

Which of the following best describes the degree of severity of your symptoms at the time of diagnosis?*

Mild

Moderate

Severe

Unknown

Are you currently being treated with CPAP or BIPAP machines?*

Yes

Hours of use per night:*

Please provide the starting date of your treatment:*

Year

Month

Day

This field is hidden when viewing the form

Please provide the starting date of your treatment:*

Has the condition been fully investigated?*

Yes

Please provide information regarding your incomplete investigation

Have you been diagnosed with central sleep apnea?*

Yes

Has your sleep apnea affected your normal daily activities?*

Yes

Please specify or clarify your condition (provide as much detail as possible)*

Please specify or clarify your condition (provide as much detail as possible)

Have you had any motor vehicle accidents in the past three (3) years?*

Yes

Diagnostic tests or exams

Name of the exam:*

Were the results confirmed to you as normal?*

Yes

Please provide more information regarding your results*

Please provide more information regarding your results

Please provide the date of the exam *

Untitled*

This field is hidden when viewing the form

Please provide the date of the exam*

Please provide more details about the test or exam*

Please provide more details about the test or exam

Name of the exam:

Were the results confirmed to you as normal?

Yes

Please provide more information regarding your results

Please provide the date of the exam

Untitled

This field is hidden when viewing the form

Please provide the date of the exam

Please provide more details about the test or exam

Name of the exam:

Were the results confirmed to you as normal?

Yes

Please provide more information regarding your results

Please provide the date of the exam

Untitled

This field is hidden when viewing the form

Please provide the date of the exam

Please provide more details about the test or exam

Medical general questionnaire

1) Please provide the exact diagnosis of your condition:*

2) When was your diagnosis made? *

Month*

This field is hidden when viewing the form

2) When was your diagnosis made?*

3) Have you had any treatments (including medication) for your condition?*

Yes

Please provide more information regarding the treatment(s) received*

Please provide more information regarding the treatment(s) received

4) Have you had any exams or tests for your condition?*

Yes

Please provide more information regarding the exams or the tests performed*

Please provide more information regarding the exams or the tests performed

5) Have you been off work or disabled because of this condition?*

Yes

Please indicate the beginning and end dates of your disability period:

Start: *

start year*

start month*

This field is hidden when viewing the form

Start:*

End: *

end year*

end month*

This field is hidden when viewing the form

End:*

Start:

start year

start month

This field is hidden when viewing the form

Start:

End:

end year

end month

This field is hidden when viewing the form

End:

Start:

start year

start month

This field is hidden when viewing the form

Start:

End:

end year

end month

This field is hidden when viewing the form

End:

6) Have you been hospitalized because of this condition?*

Yes

Please provide the dates and duration of your hospitalizations:

Date: *

date year*

date month*

This field is hidden when viewing the form

Date:*

Duration:*

Date:

date year @1

date month @2

This field is hidden when viewing the form

Date:

Duration:

Date:

date year @3

date month @3

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Date:

Duration:

7) Are you fully recovered from this condition?*

Yes

Please indicate since what date you have been fully recovered: *

Untitled

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Please indicate since what date you have been fully recovered:*

Please provide more details about your condition:*

8) Please provide any other relevant details about your condition:

Please provide any other relevant details about your condition:

1) Please provide the exact diagnosis of your condition:

2) When was your diagnosis made?

Untitled

This field is hidden when viewing the form

2) When was your diagnosis made?

3) Have you had any treatments (including medication) for your condition?

Yes

Please provide more information regarding the treatment(s) received

4) Have you had any exams or tests for your condition?

Yes

Please provide more information regarding the exams or the tests performed

5) Have you been off work or disabled because of this condition?

Yes

Please indicate the beginning and end dates of your disability period:

Start:

star year @1

start month @1

This field is hidden when viewing the form

Start:

End:

end year @1

end month @1

This field is hidden when viewing the form

End:

Start:

start year @2

start month @2

This field is hidden when viewing the form

Start:

End:

end year @2

end month @2

This field is hidden when viewing the form

End:

Start:

start year @3

start month @3

This field is hidden when viewing the form

Start:

End:

end year @3

end month @3

This field is hidden when viewing the form

End:

6) Have you been hospitalized because of this condition?

Yes

Please provide the dates and duration of your hospitalizations:

Date:

date year @1

date month @1

This field is hidden when viewing the form

Date:

Duration:

Date:

date year @2

date month @2

This field is hidden when viewing the form

Date:

Duration:

Date:

date year @3

date month @3

This field is hidden when viewing the form

Date:

Duration:

7) Are you fully recovered from this condition?

Yes

Please indicate since what date you have been fully recovered:

Untitled

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Please indicate since what date you have been fully recovered:

Please provide more details about your condition:

8) Please provide any other relevant details about your condition:

8)Please provide any other relevant details about your condition:

NON-MEDICAL QUESTIONNAIRES

Alcohol

1) Please indicate your typical alcohol consumption per week (1 consumption = 1 bottle of beer or 1 glass of wine or 1 ounce of liquor):*

2) Have you ever reduced your alcohol consumption?*

Yes

When did you begin reducing?*

Year

Month

Day

This field is hidden when viewing the form

When did you begin reducing?*

Please indicate your past alcohol consumption per week (1 consumption = 1 bottle of beer or 1 glass of wine or 1 ounce of liquor):*

Drugs

Have you ever used cannabis (marijuana, hashish, etc.)?*

Yes

Do you currently use cannabis (marijuana, hashish, etc.) or did you do so in the last year?*

Yes

When was the last time you used it? *

Month*

This field is hidden when viewing the form

When was the last time you used it?*

Please provide the average quantity and frequency of your cannabis (marijuana, hashish, etc.) use before quitting:

Consumption:*

per*

Please provide the average quantity and frequency of your current cannabis (marijuana, hashish, etc.) use:

Consumption:*

per*

Have you ever reduced your consumption?*

Yes

Please provide the average quantity and frequency of your marijuana/cannabis use before reducing:

Consumption:*

per*

When did you reduce your consumption? *

Untitled*

This field is hidden when viewing the form

When did you reduce your consumption?*

Other drugs

Have you ever used other drugs?*

Yes

Please disclose every drug usage, excluding cannabis (marijuana, hashish, etc.):

Drug type*

Last time of use *

Untitled*

This field is hidden when viewing the form

Last time of use*

Number of uses and frequency*

Per(day, week, month, etc.)*

Drug type

Last time of use

Untitled

This field is hidden when viewing the form

Last time of use

Number of uses and frequency

Per(day, week, month, etc.)

Drug type

Last time of use

Untitled

This field is hidden when viewing the form

Last time of use

Number of uses and frequency

Per(day, week, month, etc.)

Non-medical general questionnaire

For foreign travels: Countries you will visit, date of departure, duration, reasons for stay, etc.

For sports and aviation: Beginning and end date, locations, type and characteristics (be as precise as possible), accidents or injuries experienced, frequency, etc.

For criminal record: Nature of the criminal act, date, type of conviction, probation (start and end date), etc.

Please provide details here:*

Please provide details here: