Kiddy Plan Application Form

Make sure that you consult the Description of Coverage, including the procedure for filing a claim.

Enrolment by Telephone

You may enrol by telephone by contacting customer service from 8:00 a.m. to 5:00 p.m. (Eastern time), from Monday to Friday, at the following numbers:

Quebec City region: (418) 684-5405
Other regions (toll free): 1-888-266-2224

Online enrolment

Yes, I would like to take advantage of the Kiddy Plan providing free critical
illness-children insurance for 12 months*. I understand that this offer does not involve any other obligation on my part. Please bring me my critical illness insurance-children policy, as well as the mini first aid kit included with the offer.

* Mandatory information
Your first name*
Your last name*
Relationship to child*	Mother     Father     Guardian
Civic no. and street*
Apartment no.
Post Office Box
City*
Province*
Postal code*
Telephone no.*	(  )  -
E-mail
How did you hear about the Kiddy plan?* Yoopa magazine Other. Specify :
Child's date of birth #1* (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Child's date of birth #2 (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Child's date of birth #3 (DD/MM/YYYY)	January February March April May June July August September October November December
Child's first name
Child's last name
Child's sex	Girl      Boy
Reserved for Administration only Agent code Agency code
You will receive your critical illness insurance for children and the mini first aid kit in four to six weeks. The gift may differ from the one shown. Industrial Alliance Insurance and Financial Services Inc. Reserves the right to terminate this offer at any time, without notice.
This form is secure. For further information, consult the Confidentiality section.