Try for free

iA F54-361A: Group Life Insurance Claim Form

Employers and beneficiaries use this three-page form to claim group life insurance from iA Financial Group after the death of a member, spouse or dependent child. The employer completes the first page and the beneficiary the second, while page 3 holds a short Physician's Statement on the cause of death. That statement is mandatory only for larger coverage amounts; otherwise an official death certificate may be enough.

Who completes it

The physician completes and signs the Physician's Statement on page 3, covering the principal and contributing causes of death, the date of onset and the treatment period. The employer completes the Employer's Statement, and the beneficiary (claimant) completes the Beneficiary's Statement and signs the confirmation and authorization.

Submitting and payment

How to submit it
Page 3 lists fax or mail to iA's Group Life Claims as the ways to submit the form, and iA's claims page asks for it to be printed, signed by hand and sent with any required documents.

Good to know

  • The Physician's Statement is mandatory when optional life coverage, or combined basic and optional coverage, exceeds thresholds printed on the form; above them the death certificate is also required.
  • For smaller amounts the beneficiary may attach the official death certificate instead, and the claim instructions direct the smallest claims to a phone call to iA rather than this form.
  • For an accidental death, the beneficiary attaches the coroner's report, but the form says not to wait for that report before sending the other documents.
  • The statement asks whether the deceased was a smoker or non-smoker and for the period you treated them, along with the dates of death, birth and onset.

Get the official form

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

Claim form – Life insurance

Réclamation – Assurance vie

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF 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.

See how Vero Documents works

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When does iA's group life claim need the Physician's Statement?

The claim instructions say the Physician's Statement must be completed and signed when the optional life insurance amount, or the combined basic and optional amount, exceeds the thresholds printed on the form. In those cases the death certificate and the Physician's Statement are both required; otherwise the beneficiary can provide either one.

What does the Physician's Statement on F54-361A ask?

It asks for the deceased's full name, smoker or non-smoker status, dates of death and birth, place of death, the principal cause of death, any causes that contributed to death, the date of onset of the illness or event, and the dates you treated the deceased, followed by your name, signature and address.

Is iA's group life insurance claim form fillable?

Yes. The English form F54-361A, edition 25-02, is a fillable PDF, and iA publishes a French version numbered F54-361. Both are on iA's group claims page for critical illness, death and accidental dismemberment, which asks claimants to print the form, sign it by hand and send it with required documents.