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Individual Insurance - Forms
For any question regarding the form to fill or for assistance filling out a form, do not hesite to contact us at 819 478-1315 or at 1 800 567-0988, extension 2063.
To send us a form duly filed or any other document, we recommand that you send it by mail to our mailing address : P.O. Box 696, Drummondville, Quebec J2B 6W9.
You can also send it by fax at 819-474-1990 or through your financial security advisor. If you can no longer find their contact details, contact us and we will be happy to provide them.
We wish to inform you that the use of emails as means of communication to send a document or content does not guarantee the protection nor the confidentiality of the information contained in the email. However, if you wish to use email as means of communication, we invite you to first contact us by phone so we can initiate a secured transmission. |
Death
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Claimants Statement Death Claim (for life insurance issued less than 10 years ago or for a value of over $200,000)
(PDF [52.33 KB]) -
Claimants Statement Death Claim (for life insurance issued more than 10 years ago and valued at less than $200,000)
(PDF [175.94 KB]) -
Death certificate (Attending Physician)
(PDF [212.61 KB])
Disability
Critical illness
Accident
Loss of employment
Modification of name, address, owner or beneficiary
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Modification (name - address)
(PDF [160.59 KB]) -
Beneficiary Replacement
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Change / Designation of Contingent Beneficiary
(PDF [115.51 KB]) -
Policy Owner Replacement
(PDF [201.48 KB]) -
Contingent Owner Designation
(PDF [163.86 KB]) -
Authorization to release information to the physician
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Certified Copy - Resolution of the Board of Directors
(PDF [253.15 KB])
Cancellation, cash value, loan, paid-up and dividends request
Various changes and requests
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Life Insurance Application (child rider)
(PDF [140.85 KB]) -
Addition to the application (Credit Insurance rider)
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Request for Financial Advisor Replacement (Interactive PDF)
(PDF [149.77 KB]) -
Request for Policy Duplicate
(PDF [95.58 KB]) -
Modification Form
(PDF [107.86 KB]) -
Assignment - Guarantee
(PDF [133.89 KB]) -
Pre-authorized Bank Withdrawal (PAW)
(PDF [178.54 KB]) -
Retrocession
(PDF [145.87 KB]) -
Authorization letter non-resident
(PDF [107.10 KB]) -
Request for Policy Certificate
(PDF [132.10 KB]) -
Policyholder(s)/Payor(s) Identity Verification
(PDF [168.73 KB])
Application
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Application | Individual Insurance
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Eligibility Questionnaire 1 – Express for adults | Term and Permanent Life insurance and Credit Insurance Rider
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Eligibility Questionnaire 2 – Immediate for adults | Term and Permanent Life insurance and Credit Insurance Rider
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Eligibility Questionnaire 3 – Express for children | Life insurance
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Eligibility Questionnaire 4 – Additional coverages
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Application | Early Learning
Life habits
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Alcohol Questionnaire
(PDF [191.37 KB]) -
Drug Questionnaire
(PDF [193.97 KB]) -
Tobacco Questionnaire
(PDF [163.37 KB]) -
Mountain Climbing Questionnaire
(PDF [269.53 KB]) -
Parachuting and Freefall Questionnaire
(PDF [230.03 KB]) -
Scuba Diving Questionnaire
(PDF [382.82 KB]) -
Driving Questionnaire
(PDF [48.93 KB]) -
Auto Racing Questionnaire
(PDF [273.43 KB]) -
Motorcycle Questionnaire
(PDF [337.71 KB]) -
International Travel Questionnaire
(PDF [302.49 KB]) -
Aviation Questionnaire
(PDF [284.46 KB]) -
Financial Questionnaire
(PDF [123.42 KB]) -
Military Questionnaire
(PDF [126.81 KB]) -
Flight Activity Questionnaire
(PDF [321.96 KB]) -
Motor Boat Racing Questionnaire
(PDF [308.81 KB]) -
Questionnaire for Mining Workers
(PDF [116.38 KB]) -
Driver's authorization form | DynaCare Insurance solution | Saskatchewan
(PDF [40.78 KB]) -
Driver Abstract | Claim Experience Letter Request Form | Manitoba
(PDF [136.48 KB]) -
Driver's Licence Abstract Request - ICBC
(PDF [36.24 KB]) -
Authorization for the Disclosure of a Driving Record by the SAAQ
(PDF [66.42 KB])
Health
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Complementary questionnaire to the Individual Insurance Application (Credit Insurance Rider)
(PDF [221.86 KB]) -
Medical Disorder Questionnaire
(PDF [122.28 KB]) -
Headache Questionnaire
(PDF [120.68 KB]) -
Questionnaire for Mental Illness or Emotional Disorders
(PDF [124.94 KB]) -
Gastrointestinal Disorder Questionnaire
(PDF [118.78 KB]) -
Rhumatism, Arthritis or Gout Questionnaire
(PDF [121.89 KB]) -
Hypertension Questionnaire
(PDF [122.72 KB]) -
Questionnaire on Epilepsy, Convulsions and Loss of Conscience
(PDF [121.42 KB]) -
Diabetes Questionnaire
(PDF [118.78 KB]) -
Back Pain Questionnaire
(PDF [122.26 KB]) -
Respiratory Disorder Questionnaire
(PDF [124.20 KB]) -
Musculoskeletal Disorder Questionnaire
(PDF [123.82 KB]) -
Questionnaire regarding AdapCI-Hybrid Option
(PDF [193.70 KB]) -
Attention deficit disorder with or without hyperactivity Questionnaire
(PDF [169.80 KB]) -
Insurability declaration at policy delivery
(PDF [330.25 KB]) -
Declaration of insurability
(PDF [489.40 KB]) -
Insurability declaration for life (insurance children rider T25)
(PDF [535.61 KB]) -
Insurability Declaration at Policy Delivery - Child (0-15 years)
(PDF [330.25 KB])
Application
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Application | Individual Insurance (Interactive PDF)
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Eligibility Questionnaire 1 – Simplified Issue | Express for adults | Life insurance including Credit insurance
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Eligibility Questionnaire 2 - Simplified Issue | Immediate | Life insurance including Credit insurance
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Eligibility Questionnaire 3 - Simplified Issue | Express for children | Life insurance
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Eligibility Questionnaire 4 - Simplified Issue | Additional coverages
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Application | Early Learning (Interactive PDF)
Marketing Documents
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Types of simplified issue
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Summary of Additional Coverages
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Simplified Issue - Reminder for ages 16 to 80
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Simplified Issue What Sets Us Apart for Children 15 days to age 15
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Simplified Issue What sets us appart for ages 16 to 80
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Early Learning
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Juvenile 30/100
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Whole Life High Values
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Adaptable
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Whole Life Pay to 100
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Term Life Insurance
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AdapCI and AdapCI Juvenile
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Contact List for partners
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Teladoc | AdapCI