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iA Overage Dependent with a Disability (F54-923A)

iA Financial Group uses this one-page questionnaire to assess whether an overage dependent with a disability can stay covered under a group plan. The plan member describes the dependent's education, living situation, work hours and any government assistance, and the attending physician documents the diagnosis, the nature and degree of the disability, daily living limitations and whether the dependent can work for pay.

Who completes it

The attending physician completes Section 2 (patient information) and signs it, indicating general practitioner, specialist or other. The plan member completes Section 1 with the group policy and certificate numbers and the dependent's details.

Submitting and payment

How to submit it
The form is sent to iA by mail or fax according to the province of residence, with separate return details for Quebec and for all other provinces.

Good to know

  • Section 2 asks whether the patient can live alone without supervision and which activities they cannot perform: bathing, dressing, feeding, using the restroom or moving under their own power.
  • State whether the condition is permanent and stable or whether improvement can be anticipated, and whether the patient takes medication related to the disability.
  • Attach a copy of any physician or other specialist consultation reports pertaining to the patient's disability.
  • The plan member reports whether the patient, or the person responsible for them, receives government assistance, and how many hours per week the patient works if employed.

Get the official form

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

Overage dependent with a disability questionnaire

Personne à charge ayant un handicap et dépassant l'âge maximal

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.

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.

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Frequently asked questions

What does the physician complete on iA's overage dependent questionnaire?

Section 2: the diagnosis and date of onset, the nature and degree of the physical or mental disability, whether the patient can live alone without supervision, activities they cannot perform, whether the condition is permanent and stable, related medications, and whether the patient can work for remuneration or profit, with reasons if not.

Is iA form F54-923A available in French?

Yes. The French version is F54-923, titled Personne à charge ayant un handicap et dépassant l'âge maximal. The English version, F54-923A, is revision 23-06 and is sent to iA by mail or fax according to the province of residence.

What should accompany iA form F54-923A?

The form asks for a copy of any physician or other specialist consultation reports pertaining to the patient's disability. If the patient or the person responsible for them receives government assistance, the plan member names those programs in Section 1.