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iA Special Markets 6253-E: Proof of Death Physician

iA Financial Group's Special Markets division asks the deceased's physician for this one-page statement when a beneficiary claims an accidental death benefit. It records the immediate cause of death, how long the disease or impairment existed, the onset of the first symptom, other significant conditions and whether the death was an accident, suicide or homicide. The claimant and the employer or superior officer each complete their own forms.

Who completes it

The physician completes the whole statement and signs it as MD with their phone number and address. The claimant completes the Proof of Death Claimant's Statement (6252-E), and the employer completes the Certificate of Employer or Superior Officer, Death Claim (6246-E).

Submitting and payment

How to submit it
The statement's header gives the iA Special Markets Claims Department's mailing address, fax number and email for returning it; for other claim forms, the claims page says to contact the Claims Department.
Who pays
The form states that the claimant is responsible for any fee for completing it.

Good to know

  • This form looks back 5 years: whether you treated or advised the deceased in the 5 years before the last illness, and any other physician, hospital or institution that treated them.
  • It asks whether the deceased was known to be a cigarette smoker, and whether an inquest was held or an autopsy performed, by whom and with what findings.
  • Dates use the DD/MMM/YYYY format, and the immediate cause of death means the disease, injury or complication that caused death.
  • For dismemberment or loss of use under the same Special Markets coverage, the claims page lists a separate Specific Loss, Loss of Use form (6244-E).

Get the official form

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

Proof of Death - Physician Statement

Official page

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

Who pays for iA's Proof of Death Physician Statement (6253-E)?

The claimant. The form states that the claimant is responsible for any fee for its completion. It is one of three forms iA Special Markets lists for an accidental death claim, along with the Proof of Death Claimant's Statement (6252-E) and the Certificate of Employer or Superior Officer (6246-E).

How far back does the 6253-E medical history go?

Five years. The form asks whether you treated or advised the deceased during the last 5 years before the last illness, and whether, to your knowledge, they were treated by any other physician, hospital or institution in that period. If so, list each physician's name, address and the nature of the illness or injury.