VPS 107605 122744 (01/2021)
RBC Life Insurance Company is herein referred to as “the Company.”
It is understood and agreed as follows:
1. This Application for Reinstatement or Policy Change (“Application”) and any telephone interview, supplement(s), and/or questionnaire(s)
provided in support of this Application will form part of any policy change or reinstatement issued. I am responsible for the accuracy and
completeness of the information provided. I have read the statements and answers recorded on this Application and on any supplement(s),
and/or questionnaire(s) provided in support of this Application. They are true and complete and correctly recorded. I have initialed any changes
made to the answers I provided. I understand that inaccurate answers to any questions may affect my eligibility for coverage and/or benets,
and may mean that there will be no coverage.
2. I will discontinue any policy shown to be discontinued immediately upon approval of the policy change or reinstatement by the Company as
a result of this Application. The Company will rely on such answers in determining the amount, if any, of insurance it will issue. If any policy
shown to be discontinued is not discontinued, the policy change or reinstatement issued by the Company as a result of this Application shall be
3. No statement made to and no information acquired by a representative of the Company or an examining physician shall be attributed to or
binding upon the Company unless contained in the Application or any related declaration of health-related evidence of insurability. No one
other than an ofcer of the Company may (a) alter or modify the terms of this Application or Policy or (b) waive any rights or requirements of
4. The Company has the right to require medical exams and tests to determine insurability.
5. The Company shall have the right to effect the change indicated on this Application, either by cancellation of the present policy and issuance of
a substitute policy, (in which case, the policy is deemed surrendered to the Company), or by the amendment of the present policy.
6. The present policy (if not lapsed) shall continue subject to its provisions, until the change requested becomes effective.
7. The policy change or reinstatement applied for will take effect only if and when the request is approved by the Company, payment of any
outstanding premium is made, any and all conditions of the policy change or reinstatement have been satised completely, including but not
limited to, the Company’s receipt and approval of all amendments and addendums required for the policy change or reinstatement, signed
by me within the period required by the Company, and there has been no change in the health or insurability of the Insured. I will immediately
advise the Company, in writing, of any changes in the answers to the questions in this Application, including the answers to any telephone
interview questions, any other questionnaire(s) and any paramedical or medical exam (as applicable), between the date of this Application and
the approval of the policy change or reinstatement.
8. The Company is authorized to obtain an investigative consumer report on me.
9. Acceptance by the Owner of any policy change or reinstatement issued as a result of this Application will ratify any changes except that no
changes may be made as to Insurer, Form of Insurance, Reduction of Amount, Benets or Classication unless agreed to in writing by the
10. A copy of the “Consumer Fact Sheet Pre-Notice” has been received and read.
11. The Company is authorized to draw a pre-authorized debit, without prior notication, to pay any premium adjustments under the terms of the
PAD agreement already in force.
12. The incontestable clause of the policy will apply for a period of two years from the effective date of the policy change or reinstatement.
13. I have read the section entitled “Collection and Use of Personal Information” appearing in this Application and understand and agree to its
14. I understand that the Company will create and maintain at their ofce a le for the purposes of this Application and any subsequent claim. I am
entitled to consult the personal information contained in this le and, where applicable, have it rectied by formulating a written request to the
Company. Only the employees, mandataries or agents responsible for such purposes will have access to it.
15. If my Advisor or I provide any document to the Company by way of email, pdf, or fax transmission, the Company may rely on the document
as though it were an original document. The Company may assume that any email, pdf, or fax transmission that my Advisor or I send to the
Company is a reliable communication. The Company may convert any paper records related to my Application or Policy into electronic images
as part of the Company’s normal business practices. Any electronic image will be an authoritative copy of the paper record. The electronic
image will be legally binding and admissible in any legal proceeding as conclusive evidence of the contents of the paper record in the same
manner as the original paper record.
Signed at this
Signature of Insured or Parents/Guardians (tutors in Quebec) if Insured is under
age 16 years (under age 18 years in Quebec)
Signature of Owner (if different than Insured)
Signature of Irrevocable or Preferred Beneciary (if applicable)
Signature of Joint Owner (if applicable)
If Corporate Owner, provide the title of signing ofcer. If Trustee Owner, identify
* In Quebec, if there is more than one tutor
, all tutors must sign unless one tutor has been given the authority in a specic mandate to act unilaterally on the child’s behalf.
Note: If the Policy is owned by a corporation, this Application must be signed by an Ofcer of the corporation other than the Insured
(unless the Insured is the sole Ofcer of the corporation).
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