iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
1.4 Pre-Authorized Cheque Payment/Pre-Authorized Debit (PAC/PAD) Agreement
Each account holder is referred to as “I” in this PAC/PAD Agreement section and makes the following statements in respect to himself or herself.
• I authorize Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”) and the financial institution designated (or any other financial institution I may
authorize at any time) to begin deductions as per my instructions for regular recurring payments and/or one-time payments from time to time for payment of all premiums,
deposits, instalments and charges arising from the contract hereunder mentioned. Regular payments will be debited from my specified account based on the date and/or
frequency I have chosen, whereas one-time payments from time to time can be debited from my account on any other date.
• I agree that, for the purpose of this PAC/PAD Agreement, all PACs/PADs from my account will be treated as Personal unless I advise otherwise.
• I waive the right to receive pre-notification of an increase or a decrease in the amount to be debited or a change in the date and/or frequency of these payments.
• I agree that iA Financial Group is not required to provide me with written notice of a change in a PAC/PAD amount that is made as a result of my request.
• If a PAC/PAD is dishonoured for any reason such as, but not limited to, insufficient funds (“NSF”), stop payment or account closed, iA Financial Group is authorized
to re-submit the payment. Any charges incurred by iA Financial Group as a result of the dishonoured PAC/PAD will be added to the subsequent PAC/PAD.
• I may cancel or modify this PAC/PAD Agreement at any time, subject to providing iA Financial Group thirty (30) days notice in writing. To obtain a sample cancellation form or
for more information on my right to cancel the PAC/PAD Agreement, I may contact my financial institution or visit www.payments.ca concerning Rule H1 – Pre-authorized
debits (PADs).
• Any cancellation of this PAC/PAD Agreement will not affect my insurance contract(s) and/or contract(s) for financial services, so long as payment is provided by an alternate
method.
• iA Financial Group will not assign this PAC/PAD Agreement without providing, any time prior to the next PAC/PAD, written notice to me of the assignment.
• I have certain recourse rights if any PAC/PAD does not comply with this PAC/PAD Agreement. For example, I have the right to receive reimbursement for any PAC/PAD that is not
authorized or is not consistent with this PAC/PAD Agreement. To obtain more information on my recourse rights, I should contact my financial institution or visit www.payments.ca.
SIGNATURES
Is ownership of this policy joint? Yes ➜ Please obtain the signature of all policyowners.
Is the policyowner and/or the bank account holder Yes ➜ Please obtain the signature of an authorized person AND attach a copy of the company’s resolution
a company? designating the authorized signatories.
Is new banking information provided with this request? Yes ➜ The signature of the policyowner and/or the bank account holder is required. If the bank account is
joint, the signature of all bank account holders are required.
Is this a change regarding a withdrawal day, target Yes ➜ The signature of all the policyowners is preferable but not mandatory.
premium, reimbursement of loan, PAC/PAD
postponement or premium holiday?
We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by iA Financial Group inasmuch
as the latter has been accepted without modification.
I confirm that I have all the necessary authorizations from the bank account holder (if other than myself) in order to allow iA Financial Group to withdraw the premiums from the
bank account.
Signed at Province this day of
20
X X X
Agent Bank account holder if other than policyowner Policy no. 1 – Policyowner/Authorized person
!
Attention:
Signatures required if the
policyowners are other
than the policyowner
of policy no.1.
X X X
Witness Bank account holder if other than policyowner Policy no. 2 – Policyowner/Authorized person
X
Policy no. 3 – Policyowner/Authorized person
Contact information of service centres:
Quebec: iA Financial Group, Policyowner Services
1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec City, QC G1K 7M3
Telephone: 1-844-442-4636, fax: 1-866-572-1075, email: infolife@ia.ca
Toronto: iA Financial Group, Toronto Service Centre, Policyowner Services
522 University Avenue, Suite 400, Toronto, ON M5G 1Y7
Telephone: 1-844-442-4636, fax: 1-877-780-7231, email: infolife@ia.ca
Vancouver: iA Financial Group, Vancouver Service Centre, Policyowner Services
400 - 988 West Broadway, PO Box 5900, Vancouver, BC V6B 5H6
Telephone: 1-844-442-4636, fax: 1-844-739-0634, email: infolife@ia.ca
s
F4A-01
May 2020
F4A-01(20-05)
