83734 (01/2012)
Complete the Plan Administrator’s
Statement (Section A) of the Employer’s/
Client’s Statement.
Send the Employer’s/Client’s
Statement and the Attending Physician’s
Statement to the Client.
Once these forms are returned to the
Employer, send these documents to
RBC Insurance at:
P.O. Box 4435,
Station A, Toronto, ON
M5W 5Y8
Tel 416 643-4700
Toll Free 1 877 519-9501
Fax 1 800 714-8861
These forms represent initial notice of claim. Omissions or errors may
cause a delay. Additional documentation may be requested by RBC
Insurance upon review of these forms.
Employer’s/Client’s Statement
The original enrolment form and any change of beneficiary form(s).
If the Client is covered by any insurance other than with RBC Insurance,
please provide the name of the other carrier(s) in a cover letter with the
claim form.
Complete Section B of the Employer’s/Client’s Statement, and sign and date the form. Return this form to your Employer.
Have the Attending Physician’s Statement completed by your doctor and returned directly to RBC Insurance.
83734 (01/2012)
A. To be completed by Plan Administrator
Full Name of Insured Employee Date of Hire
Occupation Salary/Rate of Pay
(Attach verification of earnings) $
Amount of RBC Insurance Basic Life $
Group Life Insurance
Voluntary Life $
Effective Date of RBC Insurance
Life Insurance
Date of Last Change in
Amount of Insurance
Amount of Basic Life $
Last Change Voluntary Life $
Increase Decrease
Increase Decrease
Date of Last Worked
Reason for Ceasing Work
Have premiums
Yes – give date
If Insurance was terminated,
was Insured notified of
conversion right?
Yes – give date
Was a claim for waiver of premium
submitted to RBC Insurance?
Did the Insured apply for
Long Term Disability benefits?
Company Name If an affiliate, subsidiary, branch or employer member, give name:
Address (Street/City/Province/Postal Code) Telephone No.
Group Policy No(s). Division No. Class No.
To the attention of: Title
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83734 (01/2012)
B. To be completed by Client
Date of Birth: Policy No. Telephone No. ( )
Apt. Street City Provice Postal Code
Describe the nature of your illness and onset of symptoms:
List all physicians and hospitals where treatment was received over the past five years:
Name of Physician/Hospital Address Dates Seen
FRAUD NOTICE Any person who knowingly files a Client’s Statement containing false or misleading information is subject to criminal and
civil penalties.
, declare that the above statements are true and
complete to the best of my knowledge and belief.
(print name)
Date Signature of Client
I understand and authorize the Company (the company refers to and includes each of RBC Life Insurance Company and RBC Insurance Services Inc., and their reinsurers) to conduct such
investigation as is necessary, to gather personal information concerning me and to disclose as necessary to third parties the fact that I am making a claim to the Company for benefits.
I understand that the Company will create and maintain files, which contain personal information concerning me. I also understand that access to personal information concerning me
will be limited to, the employees of, and other persons engaged by, the Company, in the performance of their duties, or the persons to whom I have granted access, in writing, or to any
other person or organization authorized by law.
I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me, I will be permitted to review copies of documents
containing said personal information in the possession of the Company, upon paying reasonable copying charges. I further understand that I will be permitted to request access to such
documentation and have any errors in the personal information noted and corrected by formulating a written request to the Company mailed to the employee who is handling my claim.
acknowledge and agree that if I choose to use, or instruct the Company to use, any electronic communication that is not encrypted, including without limitation, any fax or email communication,
that (i) security, privacy and confidentiality cannot be ensured, (ii) such communication is not reliable and may not be received by the intended recipient in a timely manner or at all, (iii) such
communication could be subject to interception, loss or alteration, and (iv) I assume full responsibility for the risks in connection with such communication and the Company will not be
responsible or liable in any way in connection with such communication, including without limitation, any unauthorized access to or interception, loss or alteration of such communication.
Your Authorization to Disclose Personal Information
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information, records or other data regarding me, my medical
history or treatment, or my past and present income, employment, education or training, which they have in their possession or control.
Persons to whom this Authorization Applies: Any physician, nurse, counselor, psychologist, pharmacist, physiotherapist, chiropractor or other rehabilitation professional or other health care
practitioner; and also any hospital, clinic, pharmacy, or other medical facility or provider of health care or treatment; and also the provincial health insurance plan, any insurance company
or other financial institution or insurance broker or administrator; and also my employer or former employers and any of their agents performing services relating to any employee benefits or
workers’ compensation; and also any federal or provincial government department or organization, including the Workers’ Compensation Board/Workplace Safety and Insurance Board, the
CPP/QPP disability/retirement authorities, and the federal or provincial income tax authorities; and also to any other person, agency, credit bureau or institution having information, records
or data regarding me, my medical history or treatment, or my past and present income, employment, education or training.
I understand that any information, records or data received by the Company pursuant to this authorization, both medical and non-medical, will be used for the purpose of determining
coverage under the policy, evaluating my claim for benefits, my ability to return to work and/or for the purpose of assisting with the co-ordination of my return to work, for the purpose of
administering the group and/or individual plans of insurance (including life, accidental death and dismemberment and disability policies of insurance) arranged through my employer with
the Company or another insurer, for the purpose of providing ongoing claim status information to my employer at the time the claim was incurred, for the recovery of any overpayment of
benefits incurred by me, if necessary, or for the purposes of fulfilling its (or RBC Financial Group’s) legal obligations with respect to audits, anti-money laundering, terrorist financing, fraud
investigation or other criminal activities. To the extent reasonably necessary for those purposes, I authorize the Company to disclose any of the said information, records or data received: to
other insurance companies or any reinsurer; or to my employer and their insurance brokers or advisors or their benefit plan administrators; or to my physicians or health care providers; or to
any other person or organization (including physicians, health care practitioners, rehabilitation workers, vocational evaluators) employed or engaged by the Company.
I also authorize the Company to collect, use and disclose, as necessary and relevant, my personal information from any prior claim(s) and/or for any subsequent claim(s).
This authorization does not have any expiry date. It will remain valid for as long as I am claiming eligibility for benefits or services from the Company and while the Company pursues the
recovery of any overpayment of benefits incurred by me, if necessary, whether or not benefits are being paid, and whether or not either party takes the position that there has been a breach
of contract. A photocopy of this authorization, as executed by me, will be as valid as the original.
Name of Client (Please Print)
Name of Witness (Please Print)
Signature of Client
Signature of Witness
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83734 (01/2012)
Other (specify)
Name of Patient Date of Birth:
1. a) Primary Diagnosis (including any complications)
b) Secondary Diagnosis
c) Onset
d) Subjective symptoms
e) Objective findings (include current x-rays, test results, laboratory data, clinical findings, etc.)
2. Names and addresses of other treating physicians/hospitals
3. Date of first visit: Frequency:
Daily Weekly Monthly
4. Prognosis
5. In your opinion, is this individual competent to make decisions?
Yes No
RBC Insurance is requesting copies of your complete file including treatment notes, diagnostic tests and results, hospital records and specialist
consultations on this patient and is prepared to reimburse $50.00 for the costs associated with photocopying. If this amount is unreasonable
because of the extent of your patient’s file, please have your staff contact our office at 416-643-4700 or 1-877-519-9501. Any charge for the
completion of this form, however, is the responsibility of the patient.
Signature Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name Primary Care Consultant Other
(Street / City / Province / Postal Code)
Telephone No. Fax No.
P.O. Box 4435, Station A, Toronto, ON M5W 5Y8 or fax to: 1-800-714-8861
If you have any questions, call toll free 1-877-519-9501 OR 416-643-4700
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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83734 (01/2012)
Collecting your personal information
We (RBC Life Insurance Company) may from time to time collect information about you such as:
information establishing your identity (for example, name, address, phone number, date of birth, etc.) and your personal
information related to or arising from your relationship with and through us;
information you provide through the application and claim process for any of our insurance products and services; and
information for the provision of products and services.
We may collect information from you, either directly or through representatives. We may collect and confirm this information
during the course of our relationship. We may also obtain this information from a variety of sources including hospitals,
doctors and other health care providers, the MIB, Inc., the government (including government health insurance plans) and
other governmental agencies, other insurance companies, financial institutions, motor vehicle reports, and your employer.
Using your personal information
This information may be used from time to time for the following purposes:
to verify your identity and investigate your personal background;
to issue and maintain insurance products and services you may request;
to evaluate insurance risk and manage claims;
to better understand your insurance situation;
to determine your eligibility for insurance products and services we offer;
to help us better understand the current and future needs of our clients;
to communicate to you any benefit, feature and other information about products and services you have with us;
to help us better manage our business and your relationship with us; and
as required or permitted by law.
For these purposes, we may make this information available to our employees, our agents and service providers, and third
parties, who are required to maintain the confidentiality of this information. If you are insured under a group insurance
policy obtained through your employer, we may also share your information with your employer when necessary for the
services we provide to you. Your health information will not be shared with your employer without your consent.
In the event our service provider is located outside of Canada, the service provider is bound by, and the information may be
disclosed in accordance with, the laws of the jurisdiction in which the service provider is located. Third parties may include
other insurance companies, the MIB, Inc. and financial institutions.
We may also use this information and share it with RBC
companies (i) to manage our risks and operations and those of RBC
companies and (ii) to comply with valid requests for information about you from regulators, government agencies, public
bodies or other entities who have a right to issue such requests.
If we have your social insurance number, we may use it for tax related purposes and share it with the appropriate government
Your right to access your personal information
You may obtain access to the information we hold about you at any time and review its content and accuracy, and have it
amended as appropriate; however, access may be restricted as permitted or required by law. To request access to such
information or to ask questions about our privacy policies, you may do so now or at any time in the future by contacting us at:
RBC Life Insurance Company
P.O. Box 515, Station A,
Mississauga, Ontario
L5A 4M3
Telephone: 1-800-663-0417
Facsimile: 905-813-4816
Our privacy policies
You may obtain more information about our privacy policies by asking for a copy of our “Financial fraud prevention and
privacy protection” brochure, by calling us at the toll free number shown above or by visiting our web site at www.rbc.com/
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.