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
, declare that the above statements are true and
complete to the best of my knowledge and belief.
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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