Physician's proof-of-death statement for iA Special Markets (association/affinity group) accidental death claims.
- Completed by
- Attending physician
- Issued by
- iA Financial Group
- Format
- Language
- English
iA F54-856A: Group Critical Illness Claim Form
A group plan member uses this six-page form to claim a critical illness benefit from iA Financial Group for themselves, a spouse or a dependent child. The policyholder and the member complete the first four pages; the last two hold the Attending Physician's Statement, where the physician confirms the diagnoses, onset and diagnosis dates, treatment and follow-up. The completed form goes to iA by mail or fax.
Who completes it
The attending physician completes the Attending Physician's Statement on pages 5 and 6 and gives it back to the patient. The policyholder completes the Policyholder's Statement, and the member and claimant complete the member identification and Claimant's Statement and sign the confirmation and authorization.
Submitting and payment
- How to submit it
- The physician gives the completed statement to the patient, and the form is then sent to iA by mail or fax, the channels iA recommends for personal information for increased security.
- Who pays
- A note at the end of the physician's statement says the member is responsible for any fees charged to complete the form.
Good to know
- The statement asks whether the patient is a smoker and whether they previously received treatment, consulted another physician, took medication, were hospitalized or had examinations for the illness or its symptoms.
- Under Treatment, list medications with dosage and state whether the patient has had or will have tests, surgery, other treatments or hospitalization; provide copies of test results.
- Follow-up and prognosis asks for the date of first consultation, the next consultation, follow-up frequency and any referral to another physician, with their name and specialty.
- The claim form includes a limitation period notice: claims under the group policy are governed by a limitation period set by the Insurance Act or other provincial legislation.
Get the official form
Download the current version from the source each time; forms change without notice.
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.
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
Who sends the iA critical illness Attending Physician's Statement to the insurer?
The statement tells the physician to print in ink and give the completed form to the patient. The member then submits the whole claim form to iA Financial Group by mail or fax; the form notes that, for increased security, iA recommends sending personal information by mail or fax.
Who pays for the iA critical illness physician statement?
The member. A note at the bottom of the Attending Physician's Statement states that the member is responsible for any fees charged to complete the form. The statement also asks you to answer all questions and attach any documents pertinent to the analysis of the request.
Is the iA critical illness claim form available in French?
Yes. iA Financial Group publishes a French version of the form, numbered 54-856, alongside the English F54-856A on its group claims page. The English edition is dated April 2024 (24-04), and the same page lists the life insurance and accidental dismemberment claim forms.