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iA F54-380A: Accidental Dismemberment Claim Form

iA Financial Group uses this two-page claim form when a group plan member or their dependent loses a limb, sight, hearing or speech, or the use of a limb, in an accident. The employer completes Part A, the member describes the accident in Part B, and the attending physician documents the injury and the resulting loss in Part C, printed on the reverse side.

Who completes it

The attending physician completes Part C, the Attending Physician's Statement, and signs it with their address. The employer completes Part A, the Employer's Statement, and the member completes Part B, the Member's Statement, including the confirmation and authorization.

Submitting and payment

How to submit it
iA's group claims page asks claimants to print the form, sign it by hand and send it with any required documents; the form prints separate mailing addresses for Quebec and for all other provinces.

Good to know

  • If the accident caused partial or total loss of a limb, mark on the diagram where the amputation was made, and state whether there is total and permanent loss of use.
  • For sight, give the date of total and irrecoverable loss, any date of eye removal, the vision in each eye before the accident and the percentage that now remains.
  • Question 8 asks whether the injury described was solely responsible for the loss, with particulars of any contributing causes if it was not.
  • In Part B the member states whether they have applied for workers' compensation or provincial automobile insurance benefits and attaches a copy of any accident report.

Get the official form

Download the current version from the source each time; forms change without notice.

Claim form – Accidental dismemberment

Réclamation – Mutilation accidentelle

Official pagePDFVersion française

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Which part of iA form F54-380A does the physician complete?

Part C, the Attending Physician's Statement, printed on the reverse side of the claim form. It asks when the patient first consulted you for the injury, the date of last treatment, the exact nature, location and extent of the injuries, and the date of the amputation or loss of use, followed by your signature and address.

Is iA's accidental dismemberment claim form available in French?

Yes. iA Financial Group publishes the French version as form F54-380 on the same group claims page for critical illness, death and accidental dismemberment, next to the English F54-380A. The current English edition is dated 25-03 and runs two pages, with the physician's part on page 2.

How is iA form F54-380A returned?

iA's group claims page says to complete the form, print it, sign it by hand and send it to iA along with required documents, if applicable. The form itself lists two mailing addresses, one for Quebec and one for all other provinces, and the member's authorization says a photocopy is as valid as the original.