DISABILITY CLAIM GROUP

INSURANCE
INITIAL REQUEST

According to your region, please submit the completed form to:

Quebec All Other Provinces
Disability Claims Disability Claims
PO Box 790, Station B 522 University Avenue, Suite 400
Montreal, Quebec H3B 3K6 Toronto, Ontario M5G 1Y7

INSTRUCTIONS

To properly complete the form, each party should follow the instructions below.

POLICYHOLDER (Employer or plan administrator)

1. Please complete the “Policyholder’s Statement” and ensure that you answer all questions to avoid file review delays.

2. For long-term disability or waiver of premium without short-term disability coverage requests, Industrial Alliance Insurance and
Financial Services Inc. must receive the duly completed form signed by all parties six to eight weeks before the waiting period expires.

MEMBER

1. Please complete the “Member’s Statement” and ensure that you answer all questions to avoid file review delays. Don’t forget to sign the
“Member Confirmation/Authorization” in Part 8.

2. Please ensure that your attending physician completes the medical declaration that applies to your condition (physical and/or psychological). You
must also complete the “Member Identification” section AND you must sign the “Member Authorization” at the top of the physician’s
declaration.

3. Please enclose a photocopy of the benefit statement from any government plan under which you are receiving benefits (Régie des rentes du
Québec, Canada Pension Plan, workers’ compensation, auto insurance, victim of criminal act compensation, etc.)

4. Attach a copy of all correspondence received from any government plan mentioned in number 3 above (such as a letter of acceptance,
proof of payment, etc.) and, if possible, a copy of the file.

Note:

a) It is your responsibility to pay any fees that may be incurred to have this form completed by your attending physician.

b) You will be informed of any decisions that have been made as well as to request any additional information that may be required in case of
an extended disability.
c) Please return the entire document to the applicable address above. Do not detach any pages.

ATTENDING PHYSICIAN

1. Please complete the medical declaration that applies to the condition of your patient (physical and/or psychological) ensuring that you
answer all questions to avoid file review delays.

2. Please attach any other documentation pertinent to the analysis of the request (test results of various examinations carried out and specialist
consultation reports) to the form.

F54-381A(21-04) ACC PAGE 1 OF 11

 DISABILITY CLAIM GROUP
INSURANCE
INITIAL REQUEST

According to your region, please submit the completed form to:

Quebec All Other Provinces
Disability Claims Disability Claims
PO Box 790, Station B 522 University Avenue, Suite 400
Montreal, Quebec H3B 3K6 Toronto, Ontario M5G 1Y7

POLICYHOLDER’S STATEMENT
TO EXPEDITE PROCESSING, PLEASE ANSWER ALL QUESTIONS AND OBTAIN ALL REQUIRED SIGNATURES.

Type of claim: Short-term disability Long-term disability Waiver of premium

1. COVERAGE INFORMATION

Plan member’s first name Last name

Address_____________________________________________________________________________________________________________________

Postal code

Home phone no. Cell phone no.

Best time of the day to contact the plan member: AM PM

Y M D

Date of birth

Policy no. Certificate no. Class no. Division no. (If applicable)
Y M D Y M D

Plan member’s effective date of insurance with iA Financial Group Service date
Y M D Y M D

Original effective date of insurance Date of hire

Benefits Current insurance amount

Basic life insurance – Member
Basic accidental death and dismemberment – Member
Optional life insurance
1. Member
2. Spouse
3. Children
Long-term disability – Member

2. WORK SCHEDULE AND EARNINGS INFORMATION

Number of hours worked in a normal week:

If an irregular schedule, indicate the number of hours worked for each day:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Y M D

Gross salary prior to date of disability: $ Paid monthly Biweekly Weekly Effective date

Tax credits: Federal (TD1) Provincial (TPD1)

Other, please specify

F54-381A(21-04) ACC PAGE 2 OF 11

During the period of disability, has or will the plan member receive:

Statutory holiday pay Vacation pay Pay for sick days Other

Amount $ Period from to

Are you able to accommodate: A gradual return to work Modified duties

3. EMPLOYMENT INFORMATION
Y M D Y M D

Last day worked Date returned to work (if applicable)

Accident at work Yes No

Y M D

Was an accident report filed with WSIB, CSST, Worksafe BC, etc.? Yes No Date filed

On the date the disability commenced was the employee: On vacation Laid off On paid leave On unpaid leave

On disciplinary suspension with pay On disciplinary suspension without pay Other

If returned to work please specify: Full time Part time Regular duties Modified duties

On the date the plan member last worked, what was the member’s:

Occupation Please attach a job description if available

How long has the member worked in this position? Number of years Number of months

If the plan member changed jobs or assignments during the 12 months immediately before the last day worked, describe the previous position
and provide the reason(s) for the change in job.

Please provide any other comments relevant to this claim:

4. WORK DEMANDS INFORMATION

Please complete or attach a physical demands analysis (PDA)

During the plan member’s normal routine, what percentage of time is he or she required to lift or carry:
Never 1-25% 26-50% 51-75% 76-100%
More than 10lbs/4.5 kg
More than 20lbs/9.1 kg
More than 50lbs/22.7kg

F54-381A(21-04) ACC PAGE 3 OF 11

During the plan member’s normal routine, what percentage of time does the job involve the following activities:
Never 1-25% 26-50% 51-75% 76-100%
Walking
Climbing
Driving
Reaching above shoulder height
Reaching at shoulder height
Reaching below shoulder height
Bending or crouching
Kneeling or crawling

How long is the plan member required to remain continuously engaged in the following activities without break:
0-30 minutes 31-60 minutes 61-90 minutes more than 90 minutes
Continuous sitting
Continuous standing

Mental demands
During the plan member’s normal routine, what percentage of time does the job involve the following activities:
Never 1-25% 26-50% 51-75% 76-100%
Supervision of others
Tasks with time management pressures
Tasks requiring significant attention to detail

5. POLICYHOLDER INFORMATION

Policyholder’s name

Address Postal code

Telephone no. Extension

Email address

Authorized person’s name

Y M D

Date
Signature

Name

Telephone no. Extension

Email address

iA Financial Group is a business name and trademark of

Industrial Alliance Insurance and Financial Services Inc.

1-877-422-6487 ia.ca F54-381A(21-04) ACC PAGE 4 OF 11

 DISABILITY CLAIM GROUP
INSURANCE
INITIAL REQUEST

According to your region, please submit the completed form to:

Quebec All Other Provinces
Disability Claims Disability Claims
PO Box 790, Station B 522 University Avenue, Suite 400
Montreal, Quebec H3B 3K6 Toronto, Ontario M5G 1Y7

Type of claim: Short-term disability Long-term disability Waiver of premiums

MEMBER’S STATEMENT
TO EXPEDITE PROCESSING, PLEASE ANSWER ALL QUESTIONS AND OBTAIN ALL REQUIRED SIGNATURES.

PART 1 – IDENTIFICATION

First name: Last name: Gender: Female Male

Policy no: Social Insurance Number: Certificate no.:

Y M D

Date of birth: Occupation: Language: French English

Telephone:

PART 2 – REASON FOR THE CLAIM

1. Accident. If the sick leave was the result of an accident, indicate:
- Place of the accident: Home Work Elsewhere (specify)
Y M D

- Date of the accident: Circumstances:

- If a car accident, specify whether you were: Driver Passenger If not a Quebec resident, please submit the police report.
2. Is the period of disability due to work-related problems? No Yes Specify:

PART 3 – OCCUPATION
Y M D Y M D

Date hired: When did you become unable to work? Date:

1. Explain how your condition is preventing you from working.

2. Describe the duties of your job that you can no longer perform.

3. When you stopped working, were you working anywhere else (second job)? If yes, specify:

PART 4 – CURRENT SITUATION

1. Are you confined to your home? No Yes
Confined to your bed? No Yes
Hospitalized? No Yes
2. Please describe all your symptoms including severity and frequency:

3. Describe your current activities of daily living since going on sick leave:

F54-381A(21-04) ACC PAGE 5 OF 11

PART 5 – INCOME FROM OTHER SOURCES
Indicate if you have applied or will be applying for benefits from any of the following sources:
- Commission de la santé et de la sécurité du travail (CSST) or other workers’ Y M D
compensation board No Yes Date
- Société de l’assurance automobile du Québec (SAAQ) or other automobile Y M D
insurance organization No Yes Date
Y M D
- Human Resources and Social Development Canada (HRSDC) No Yes Date
Y M D
- Régie des rentes du Québec (RRQ): Disability pension Retirement pension No Yes Date
Y M D
- Canada Pension Plan (CPP): Disability pension Retirement pension No Yes Date
Y M D
Other (specify): Date

If you have already applied for benefits, please provide a copy of all correspondence, including the decision, if applicable.
PART 6 – PHYSICIANS AND HISTORY
Y M D
1. Name of your attending physician: Date of initial visit:

Address:
Y M D
2. Have you been hospitalized for this medical condition? No Yes Date:

Name of hospital:

3. When did your symptoms start?

4. When did you first consult a physician for this medical condition?
Y M D
5. Have you ever had a similar illness or injury before? No Yes Date:
6. Would you be able to return to work gradually? No Yes
7. Has your attending physician prescribed medication? No Yes
If so, are you taking it regularly? No Yes
8. List all the physicians who have treated you in the last two years

Illness Consultation or Treatment prescribed, Name and address

treatment date medication, other of physician

PART 7 – DIRECT DEPOSIT

Disability benefits are paid by direct deposit, i.e. electronic transfer to a bank account.
To receive your benefits:
1. Provide your bank account information
2. Attach a void cheque or a sample cheque generated by your financial institution’s online services

1. Cheque number (do not write this number).

2. Transit number (5 digits).
3. Financial institution number (3 digits).
4. Account number up to 12 digits. The format may vary from one financial institution to another (indicate all the numbers).

F54-381A(21-04) ACC PAGE 6 OF 11

PART 8 – MEMBER CONFIRMATION/AUTHORIZATION
I CONFIRM that the statements provided in the Member’s Statement and all statements provided in any personal or telephone interviews concern-
ing this disability claim are true and complete to the best of my knowledge. I AGREE that all such statements form the basis for any benefits
approved as a result of this claim.
I HEREBY AUTHORIZE:
(i) Any healthcare provider or professional, medical organization, the MIB Inc., insurance or reinsurance company, investigation and credit
reporting agency, workers’ compensation board, the policyholder, my employer, as well as any other person, private or public organization
or institution acting on the employer’s behalf to disclose and exchange any personal or health information, records (including physicians’
notes) or knowledge concerning myself with Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”), its employees,
reinsurers or agency acting on behalf of iA Financial Group which is necessary for the purpose of assessing my disability claim;
(ii) iA Financial Group to exchange any information with my employer/policyholder for the purpose of assessing my disability claim or discussing
rehabilitation and return to work planning; and
(iii) iA Financial Group and my employer/policyholder to use my SIN for identification purposes in the handling of my claim.
(iv) iA Financial Group to deposit in my bank account, using the banking information I have provided above, any amounts payable in regards to
a disability claim that I submit under my group insurance plan. I confirm that I am the or one of the holders of this account and that I have
obtained all necessary authorizations, if applicable, to enrol in this direct deposit. I agree that this authorization will apply until such time as I
submit a written request to the contrary to iA Financial Group. I understand that iA Financial Group will have no further obligation with
regards to the claims paid. I also understand that iA Financial Group can, without prior notice, terminate the direct deposit of my claims
payments. This authorization takes effect on the date indicated below and will be valid for all other active bank accounts at this or any other
financial institution that I may name in the future. Furthermore, I understand and agree that if I provide iA Financial Group with incorrect
banking information or if I fail to notify iA Financial Group of any change in my banking information and, as a result of this error or omission,
the amount of a paid disability claim is deposited into the wrong bank account, iA Financial Group cannot be held responsible or liable
for this error or omission or be obligated to reimburse me if iA Financial Group is unable to recover the amount that was paid into the
wrong account.
A photocopy of this Confirmation/Authorization shall be as valid as the original.
This Confirmation/Authorization is valid only for this disability claim.

Y M D

Member’s signature: Date:

Address: Postal code:
Home: Work:

iA Financial Group is a business name and trademark of

Industrial Alliance Insurance and Financial Services Inc.

1-877-422-6487 ia.ca F54-381A(21-04) ACC PAGE 7 OF 11

 DISABILITY CLAIM GROUP
INSURANCE
INITIAL REQUEST

According to your region, please submit the completed form to:

Quebec All Other Provinces
Disability Claims Disability Claims
PO Box 790, Station B 522 University Avenue, Suite 400
Montreal, Quebec H3B 3K6 Toronto, Ontario M5G 1Y7

Type of claim: Short-term disability Long-term disability Waiver of premiums

MEMBER IDENTIFICATION (THE MEMBER MUST COMPLETE THIS SECTION)

First name: Last name:

Policy no: Social Insurance Number: Certificate no.:

Y M D

Date of birth:

MEMBER AUTHORIZATION
I HEREBY AUTHORIZE any healthcare provider or professional, medical organization, the MIB Inc., insurance or reinsurance company, investiga-
tion and credit reporting agency, workers’ compensation board, the policyholder, my employer, as well as any other person, private or public
organization or institution to disclose and exchange any personal or health information, records (including physicians’ notes) or knowledge con-
cerning myself with Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”), its employees, reinsurers or agency acting on
behalf of iA Financial Group which is necessary for the purpose of assessing my disability claim.
A photocopy of this Authorization shall be as valid as the original.
This Authorization is valid only for this disability claim.
Y M D

Member’s signature Date:

Address: Postal code:

Home: Work:

ATTENDING PHYSICIAN’S STATEMENT – PSYCHOLOGICAL ILLNESS

Please print and give to the patient
PLEASE ANSWER ALL QUESTIONS AND ATTACH ANY DOCUMENTS PERTINENT TO THE ANALYSIS OF THE REQUEST

PART 1 – DIAGNOSIS

1. Primary diagnosis: (Axis I)

2. Secondary: (Axis II, III ) Personality disorders and other medical conditions.

3. Among the current symptoms, please identify the ones that you observed during office visits.

4. Degree of severity of all symptoms: Mild Moderate Severe with psychotic elements
5. Does the interruption of work result from problems related to:
Marital/family life Loss of employment or layoff Alcohol or drug abuse and/or gambling problems
Personal or interpersonal problems Professional problems
Other problems (specify):
6. Current Global Assessment of Functioning (GAF) score:
7. Highest level of functioning (GAF score) within the last year (0-100):
8. Current mental status examination (psychomotor activity, mood, affect, thinking, cognitive abilities):

9. For the illnesses or associated symptoms diagnosed, has the patient previously:
Received medical treatments Consulted another physician Taken medication Been hospitalized

Undergone examinations Specify the dates of previous episodes: __________________________________________________________

F54-381A(21-04) ACC PAGE 8 OF 11

PART 2 – LIMITATIONS AND RESTRICTIONS

1. What are your patient’s current limitations (what he/she cannot do)?

2. What restrictions are currently placed on your patient (what he/she should not do)?

3. Is the patient able to attend his/her affairs, particularly the endorsement of cheques? No Yes

PART 3 – TREATMENT

1. Medication (name and dosage):

2. Medication strategies
Progressive increase:
Potentialization:

Combinations:
Medication changes:
3. Is the patient consulting: Psychiatrist? No Yes A social worker? No Yes
Psychologist? No Yes Another healthcare worker? No Yes
If yes, name of the healthcare provider:_____________________________________________________________________________________
Y M D Y M D

4. Hospitalization: From to
Name of hospital:

PART 4 – FOLLOW-UP AND PROGNOSIS

Y M D

1. Date of first consultation for this disability:

Y M D Y M D

Starting date of disability: Next consultation:

Y M D

2. Dates of other consultations: Follow-up frequency:

3. Will the patient be referred to a psychiatrist? No Yes Name of physician:

4. Approximate duration of disability: Number of weeks or number of months or undetermined
Y M D

or date of return to work:

Y M D

5. When will your patient be fit to return to work?

Part-time Full-time If gradual return , please explain why

6. Recommended return to work plan: Program start date:

Y M D Y M D

Week 1: days a week Date: Week 2: days a week Date:

Y M D Y M D

Week 3: days a week Date: Week 4: days a week Date:

PART 5 – IDENTIFICATION OF THE ATTENDING PHYSICIAN

1. First and last name: Telephone:

2. Address: Fax:

3. General practitioner Specialist Other Specify:___________________________________________________________________

Y M D

Signature: Date:

NOTE: THE MEMBER IS RESPONSIBLE FOR ANY FEES CHARGED TO COMPLETE THIS FORM.
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.

1-877-422-6487 ia.ca F54-381A(21-04) ACC PAGE 9 OF 11

 DISABILITY CLAIM GROUP
INSURANCE
INITIAL REQUEST

According to your region, please submit the completed form to:

Quebec All Other Provinces
Disability Claims Disability Claims
PO Box 790, Station B 522 University Avenue, Suite 400
Montreal, Quebec H3B 3K6 Toronto, Ontario M5G 1Y7

Type of claim: Short-term disability Long-term disability Waiver of premiums

MEMBER IDENTIFICATION (The member must complete this section)

First name: Last name:

Policy no: Social Insurance Number: Certificate no.:

Y M D

Date of birth:

MEMBER AUTHORIZATION
I HEREBY AUTHORIZE any healthcare provider or professional, medical organization, the MIB Inc., insurance or reinsurance company, investiga-
tion and credit reporting agency, workers’ compensation board, the policyholder, my employer, as well as any other person, private or public
organization or institution to disclose and exchange any personal or health information, records (including physicians’ notes) or knowledge con-
cerning myself with Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”), its employees, reinsurers or agency acting on
behalf of iA Financial Group which is necessary for the purpose of assessing my disability claim.
A photocopy of this Authorization shall be as valid as the original.
This Authorization is valid only for this disability claim. Y M D

Member’s signature Date:

Address: Postal code:

Home: Work:

ATTENDING PHYSICIAN’S STATEMENT – PHYSICAL ILLNESS

Please print and give to the patient
PLEASE ANSWER ALL QUESTIONS AND ATTACH ANY DOCUMENTS PERTINENT TO THE ANALYSIS OF THE REQUEST

PART 1 – DIAGNOSIS
1. Primary:

2. Secondary:

3. Complications:
4. For the illnesses or associated symptoms diagnosed, has the patient previously:
received medical treatments consulted another physician taken medication been hospitalized
undergone examinations Specify the periods:
5. a) Is the disability related to the specific risks of this patient’s job?
No Yes If so, explain:
b) Is the disability related to: Accident Illness Work accident Occupational illness
Y M D

Motor vehicle accident Date of the event:

Y M D

c) Pregnancy? No Yes Expected date of delivery:

Y M D

Preventive leave? No Yes Start date:

6. Describe the functional limitations that prevent the patient from carrying out professional duties or usual daily activities.
Date At the beginning of disability Currently
Y M D

Y M D

Y M D

Height: m Weight: kg Right-handed Left-handed

F54-381A(21-04) ACC PAGE 10 OF 11
PART 2 – LIMITATIONS AND RESTRICTIONS

1. What are your patient’s current limitations (what he/she cannot do)?

2. What restrictions are currently placed on your patient (what he/she should not do)?

3. Cardiac status (if related to the disability):

a) Functional capacity (American Heart Association) Class I (no limitation) Class II (slight limitation)
Class III (marked limitation) Class IV (severe limitation)
b) Blood pressure (last visit): Systolic Diastolic
c) Is the patient able to attend his/her affairs, particularly the endorsement of cheques? No Yes

PART 3 – TREATMENT
1. Medication (name and dosage):

2. Has the patient undergone or will undergo:

a) Examinations or tests? No Yes Specify:
Y M D

b) Surgery? No Yes Day surgery Type: Date:

Surgical procedure:

c) Other treatments? No Yes Specify:

Y M D Y M D

d) Hospitalization: From to

Name of hospital:

e) A short stay under observation (number of hours):

PART 4 - FOLLOW-UP AND PROGNOSIS
Y M D

1. Date of first consultation for this disability:

Y M D Y M D

Starting date of disability: Next consultation:

Y M D

2. Dates of other consultations: Follow-up frequency:

3. Referral to another physician? No Yes Name of physician:

Speciality :

4. Approximate duration of disability: Number of weeks or number of months or undetermined

Y M D

or date of return to work:

Y M D

5. When will your patient be fit to return to work?

Part-time Full-time If gradual return, please explain why

Y M D

6. Recommended return to work plan: Plan start date:

Y M D Y M D

Week 1: days a week Date: Week 2: days a week Date:

Y M D Y M D

Week 3: days a week Date: Week 4: days a week Date:

PART 5 – IDENTIFICATION OF THE ATTENDING PHYSICIAN
1. First and last name: Telephone:

2. Address: Fax:

3. General practitioner Specialist Other Specify:____________________________________________________________________

Y M D

Signature: Date:
NOTE: THE MEMBER IS RESPONSIBLE FOR ANY FEES CHARGED TO COMPLETE THIS FORM.
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.

1-877-422-6487 ia.ca F54-381A(21-04) ACC PAGE 11 OF 11