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					                                                                                                                  FInAnCIAL	SERvICES	InCLuDIng	InSuRAnCE,	
                                                                                                                  AnnuITIES,	CREDIT	AnD	RELATED	SERvICES




          P.O.	Box	4593	STn	A	Toronto,	On		M5W	4X7
                                                                                                                       disability claim

     Important InformatIon

     the following documents are required in order to process your claim. incomplete or missing documents may delay this process.



     Disability Income Insurance benefits
        if you are submitting a disability income insurance benefit claim, please fill out the following forms and send them to dFs:
        •	This	Disability	Claim	form	(no.	09044E).
        •	The	Declaration	of	Attending	Physician	–	Original	Request	form	(no.	02025A).
        •	If	you	are	a	salaried	employee,	a	copy	of	your	income	tax	returns	for	your	three	highest	years	of	earnings	over	the	past	five	
          calendar	years,	or	your	income	tax	return	confirming	your	earnings	for	your	last	full	year	of	work	prior	to	your	disability.	
        •	If	you	own	a	business	or	have	an	interest	of	20%	or	more	in	a	business	in	which	you	are	actively	involved,	a	copy	of	the	company’s	
          income	tax	returns	for	the	three	most	profitable	of	the	last	five	calendar	years	that	confirms	your	share	in	the	business,	and	a	copy	
          of	the	income	statement	for	the	company	or	for	your	professional	activities	for	your	last	full	year	of	work	prior	to	your	disability.




     Partial Disability Income Insurance benefits
        If	you	are	submitting	a	Partial	Disability	Income	Insurance	benefit	claim,	please	fill	out	the	following	forms	and	send	them	to	DFS:
        •	All	of	the	documents	required	for	a	Disability	Income	Insurance	benefit	claim.
        •	The	Additional	Statement	form	(no.	09045E).




     Residual Disability Income Insurance benefits
        If	you	are	submitting	a	Residual	Disability	Income	Insurance	benefit	claim,	please	fill	out	the	following	forms	and	send	them	to	DFS:
        •	All	of	the	documents	required	for	a	Disability	Income	Insurance	benefit	claim.
        • if you own a business, the Detailed	statement	of	overhead	expenses	and	income	earned	in	the	case	of	residual	disability form
        	 (no.	09111E).




     Business Expense Insurance benefits
        If	you	are	submitting	a	Business	Expenses	Insurance	benefit	claim, please fill out the following forms and send them to dFs:
        •	All	of	the	documents	required	for	a	Disability	Income	Insurance	benefit	claim.
        •	The	Business	expense	statement	form	(no.	09110E).




     Living Expenses Insurance benefits
        If	you	are	submitting	a	Living	Expenses	Insurance	benefit	claim,	please	fill	out	all	of	the	forms	required	for	a	Disability	Income	
        insurance benefits claim and send them to dFs.




     Accident Disability Income Insurance benefits
        If	you	are	submitting	an	Accident	Disability	Income	Insurance	benefit	claim	as	described	in	your	booklet,	please	fill	out	all	of	the	
        forms required for a disability income insurance benefits claim and send them to dFs.



09044E01	(09-05)                                                                                                                               Page	1	of	4
           If YoU ARE A SALARIED EmPLoYEE AnD YoUR EmPLoYER IS tHE contRAct HoLDER, PLEASE HAVE YoUR EmPLoYER fILL oUt
             SEctIonS E AnD f fIRSt. If YoU ARE A SELf-EmPLoYED woRkER, PLEASE AnSwER tHE foLLowInG qUEStIonS YoURSELf.

A - IDEntIfIcAtIon
Insured’s	last	name	and	first	name                                                                                                      date of birth
                                                                                                                                               aa              mm             JJ


Number, street, apartment                                                    Policy	number(s)	                                          Social	insurance	number	(if	taxable)

City,	province	                                       Postal	code	           Insured’s	telephone	number
	                                                     	                      Home	:		(	            )	      -	                 Office	:	 (	                )	             -
Advisor	name	                                         	                      	                     	    Advisor’s	telephone	number
	                                                     	                      	                     	    	     (	           )	                       -
B - GEnERAL InfoRmAtIon
1.	 Training:
 	 Level	of	education:
 	 Work	experience:
2.	 Spoken	language:	            French               		English	                  Written	language:	          French           		English
3.		 Are	you	planning	to	travel	outside	Canada	or	the	uSA	in	the	next	twelve	months?	            yes       no	    If	so,	how	long	do	you	plan	to	be	away?
c - HEALtH InfoRmAtIon
4.	 Is	the	leave:		      total           		Partial	          		Residual	          In	the	case	of	a	partial	or	residual	leave,	please	fill	out	also	form	no.	09045E.
                                                                                                                                                    yy              mm             dd
5.	 If	you	have	returned	to	your	occupation,	indicate	the	date	of	the	return	to	work
                                                                                                                                                    yy              mm             dd
6.	 If	you	have	not	returned	to	your	occupation,	indicate	the	approximate	or	scheduled	date	of	return	to	work	
                                                                                                                                                         yy         mm        dd
7.	 Were	you	in	an	accident?		     yes       No if so:         	workplace	      car     other:                       date of the accident:
8. description of the accident




9.	 Please	explain	how	your	condition	prevents	you	from	working




10.	 Describe	briefly	your	present	daily	activities	since	you	stopped	working




11.	 name	and	addresses	of	the	physicians	who	are	treating	or	have	treated	you	for	this	condition




D - mEDIcAL HIStoRY - to be completed if you have been insured for less than two years. (Please use another sheet, if necessary)
12.	 In	the	past,	did	you	consult	a	physician	or	a	health	care	professional,	or	were	you	hospitalized	for	any	health	problems?
         yes     No if so, please fill out the following table:
  name of physicians or health care            medical problem(s) or                                   name of the establishment(s)
   professionals who treated you                    diagnosis                  consultation date(s)    where you were hospitalized              Hospitalization period(s)

                                                                                                                                       from                    to

                                                                                                                                       from                    to

                                                                                                                                       from                    to

                                                                                                                                       from                    to
                                                                                                                                                                             Page	2	of	4
D - mEDIcAL HIStoRY - (cont’D)
13.		If	you	did	not	consult	a	health	care	specialist,	did	you	have	any	symptoms	related	to	your	current	health	problem	in	the	past?
         yes        No        if so, please fill out the following table:
                          Description of symptoms                                                       Description of treatments                                          Periods

                                                                                                                                                      from                       to

                                                                                                                                                      from                       to

                                                                                                                                                      from                       to

E - PRofESSIonAL ActIVItIES - If you are a salaried employee and your employer is the contract holder, please have an authorized representative of your
                                            employer answer questions 20, 21, 22, 23 and 24. If you are a self-employed worker, please answer the following questions
                                            yourself.

14.		Company	or	employer’s	name:		                                      	                                                             Telephone	number:	 (																)													-
15.		Company	or	employer’s	address:	
16.		Are	you	a	salaried	employee?		              yes              No
17.		Business	type	(if	applicable):		       an incorporated company                            a partnership                  a solo proprietorship company
                                                                                                                                              yy      mm        dd
18.		Percentage	of	shares	held	in	the	company	(if	applicable):				                         	                        Since	when:	
                                                                                                                                              yy      mm        dd
19.		Occupation:		         	 	       	 	          	 	             	 	            	         	             	          Since	when:	
	    Is	it	a	seasonal	occupation?	         yes        No          Number of months per calendar year:                                From                            to
     If	so,	are	you	engage	in	other	occupations	or	do	you	perform	other	work	during	the	year?                          yes                                 No

     if so, please indicate and describe your schedule:

                                   yy        mm         dd                                                                                                                  yy        mm         dd

20.	 Last	day	of	work:	                                                              number	of	hours	worked:                                21.	Starting	date	of	job:		
22.		What	is	the	usual	work	schedule?		
23.	 What	is	the	average	number	of	hours	worked:	      	in	the	four-week	period	prior	to	this	disability:	
	 	                                	     	              in	the	60	days	prior	to	this	disability:	
24.		Over	the	past	year:
	 a)	Has	the	level	or	nature	of	your	responsibilities	changed?          yes           No
	    	 If	so,	please	explain:	


	    b)	Were	the	tasks	modified?                           yes              No
	    	 If	so,	please	explain:		


	    c)	In	your	opinion,	is	the	employee’s	current	state	of	health	related	to	work?	                     yes         No
	      If	so,	please	explain:	


	    d)	Have	you	had	different	employers	or	been	self-employed	during	the	last	five	years?			                          yes               		no		    If	so,	please	explain
                      name	and	address	of	employer	or	business	                                                Duration	of	employment	                               Type	of	work

                                                                                                      From                    to

                                                                                                      From                    to


f - PHYSIcAL woRk EnVIRonmEnt – If you are a salaried employee, please ask an authorized representative of your employer to complete this section. If you
                                                      are a self-employed worker, please answer the following questions yourself. Please attach a brief job description if available.
25.	 What	are	the	main	duties	of	the	employee’s	job	and	how	much	time	is	allocated	to	each	one	weekly?
Duty                                                                                              % Duty	                                                                                                   %
Duty                                                                                              % Duty	                                                                                                   %
                                                  for questions 26 and 27, fREqUEncY is defined as follows:
      occASIonALLY: 0-15 % of the time                            fREqUEntLY: 16-50 % of the time                                                   ALwAYS: 51 % + of the time
26.	 Work	environment	-	Does	the	employee’s	job	require	work	in	any	of	the	following	conditions?
        fREqUEncY:                          o     f     A                        fREqUEncY:                               o     f    A                fREqUEncY:                            o       f   A
	 	 Outside	                                                	                    In	a	damp	or	humid	environment	                                      Below	ground	level	
	 	 In	extremes	of	cold	or	heat	                            	                    Toxic	fume	                                                          Handling chemicals
Does	the	job	involve	other	hazards?	                       Yes	              no	       If Yes, please list:

27.	 Check	the	items	below	that	relate	to	the	employee’s	job,	and	complete	the	information	requested.
       fREqUEncY:                    o f A                      fREqUEncY: o f A                                                                                     fREqUEncY:            o    f       A
		      Standing	                                                                Bending	over	                                     Extending/reaching	above	head
		      Walking	                                                                 Kneeling	                                         Climbing
		      Sitting	                                                                 Crouching	                                        	 Stairs	(no.	of	steps	______________)
		      Keeping	one’s	balance	                                                   Crawling	                                         	 Ladders	(Height	________________)

                                                                                                                                                                                               Page	3	of	4
f - PHYSIcAL woRk EnVIRonmEnt– (cont’D)
      DESCRIBE	ACTIvITY	AnD	SPECIFY	FREquEnCY	AnD	WEIgHT:	                                                                                    FREquEnCY	:          O	 F	 A	 WEIgHT:
           	 Pushing	                                                                                                                                                                                  lb	   kg
           	 Pulling	                                                                                                                                                                                  lb	   kg
        	 Lifting/carrying	                                                                                                                                                                            lb	   kg
      Please	list	any	office	equipment,	motor	vehicle,	tools	or	other	equipment	that	is	used	in	the	employee’s	job.
      type of equipment                                                               times per day           type of équipment                                                              times per day


      		                      Last	name	and	first	name	                               	                             Position	                                     Telephone	number	 		                            	
  EmPLoYER’S
    	                         	                                                       	                             	                                             (															)																-
  AUtHoRIZED
REPRESEntAtIVE                Signature                                                                                                                           Date
G - cURREnt BEnEfItS
28.	 Have	you	applied	for	any	other	benefits?			                   yes          No        if so, please complete this section:

      Have you filed a claim with the following organizations?                                                   Date of                was your claim
                                                                                                                                                                  monthly amount                   file no.
                                                                                                                your claim                 accepted?
                                                                                                              yy       mm     dd
                                                                                                                                          yes        No
Employment	Insurance	                                            yes      No               Retirement                                                         $
                                                                                                                                        		under	review
                                                                 yes:    disability        Retirement         yy       mm     dd
                                                                                                                                          yes        No
Régie	des	rentes	du	québec
                                                                 No                                                                     		under	review        $
                                                                 yes:    disability        Retirement         yy       mm     dd
                                                                                                                                          yes        No
Canada	Pension	Plan
                                                                 No                                                                     		under	review        $
Société	de	l’assurance	automobile                                                                             yy       mm     dd
                                                                                                                                          yes        No
                                                                         yes              No
du	québec                                                                                                                               		under	review        $
Workers’	Compensation	Board	                                                                                  yy       mm     dd
                                                                                                                                          yes        No
                                                                 yes       No             Not eligible
(CSST,	WCB,	WSIB,	WHSCC)                                                                                                                		under	review        $
                                                                                                              yy       mm     dd
Retirement	plan	(pension	fund)                                           yes              No                                              yes        No
                                                                                                                                        		under	review        $
                                                                                                              yy       mm     dd
québec	Parental	Insurance	Plan	                                                                                                           yes        No
                                                                         yes              No
qPIP	(or	equivalent)                                                                                                                    		under	review        $
Other(s)	insurer(s):          Name:
    yes       No              address:                                                                                                    yes        No
                                                                                                                                        		under	review        $
    	Individual	              File	or	policy	no.:	
    	group	                   Contact	person:	
                                                     Please provide us with the notice of acceptance or refusal for the claim you filed.

29.	 Do	you	have	other	sources	of	income?	                               yes              No       if so specify:
            salary                  Paid	vacation	               Sick	leave	                   Dividends	                   Other:	
	     Amount:	$				                                                  	                      Period	covered:
30.		 Do	you	have	any	other	insurance	coverage	with	Desjardins	Financial	Security?
           	   	                                                                                                    Policy	or	contract	no.	-	Identification	no.
	     Check	appropriate	box:
               Personal	(individual)	insurance	
                     group	insurance	coverage	through	your	employer	
                     loan insurance at your caisse or credit union
                     Accirance	-	accident	insurance	
                     Desjardins	popular	insurance	
                     mortgage loan
                     Other	

H - PERSonAL InfoRmAtIon mAnAGEmEnt
Desjardins	Financial	Security	(DFS)	handles	the	personal	information	it	has	on	you	in	a	confidential	manner.	DFS	keeps	this	information	on	file	so	that	you	may	benefit	
from	the	Company’s	various	financial	services	(insurance,	annuities,	credit,	etc.).	This	information	is	consulted	solely	by	DFS	employees	who	need	to	do	so	in	the	course	
of	their	work.	You	have	the	right	to	consult	your	file.	You	may	also	have	information	corrected	if	you	demonstrate	that	it	is	inaccurate,	incomplete,	ambiguous	or	not	useful.	
To	do	so,	you	must	send	a	written	request	to	the	following	address:	Privacy	Officer,	Desjardins	Financial	Security,	200,	rue	des	Commandeurs,	Lévis,	québec,	g6v	6R2.	
DFS	may	send	information	on	its	promotions	or	offer	new	products	to	those	whose	names	appear	on	its	client	list.	DFS	may	also	give	its	client	list	to	another	component	
of	the	Desjardins	group	for	the	same	purposes.	If	you	do	not	wish	to	receive	these	offers,	you	may	have	your	name	removed	from	the	list.	To	do	so,	you	must	send	a	
written	request	to	the	Privacy	Officer	at	DFS.

I - DEcLARAtIon AnD AUtHoRIZAtIon foR tHE coLLEctIon AnD commUnIcAtIon of PERSonAL InfoRmAtIon - to be completed
                                                                                                                                                                           for each claim
I hereby authorize Desjardins financial Security to exchange information concerning this disability file with my advisor/rep:                          Yes          no
All	the	information	I	have	provided	on	the	claim	form	is	accurate	and	complete.	I	acknowledge	having	read	the	Personal	Information	Management	section	and	the	
brochure	explaining	the	Solo	product	that	was	given	to	me	with	my	policy	when	I	enrolled	in	this	coverage.	I	authorize	Desjardins	Financial	Security,	strictly	for	the	
purposes	of	managing	my	file	and	settling	this	claim	to:	(a)	collect	from	any	person	or	legal	entity,	or	from	any	public	or	parapublic	organization,	only	the	information	
deemed	 necessary	 to	 manage	 my	 file.	The	 non-exhaustive	 list	 of	 sources	 from	 which	 information	 may	 be	 collected	 includes	 health	 care	 professionals	 or	 facilities,	
insurance	companies;	(b)	communicate	to	the	said	persons	or	organizations	only	the	personal	information	about	me	that	is	deemed	necessary	for	the	purposes	of	my	
file;	(c)	when	necessary	use	the	personal	information	it	may	have	about	me	in	existing	files	that	are	now	closed.	This	authorization	is	also	valid	for	the	collection,	use	and	
communication	of	personal	information	concerning	my	dependents,	insofar	as	applicable	to	the	claim.	A	photocopy	of	this	authorization	is	as	valid	as	the	original.

Signature of the insured person                                                                                          Date
                                                                                                                                                                                                   Page	4	of	4

				
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