Fillable APCTO FO RSTTT O POCY CG Life Insurance (RBC Insurance)

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APCTO FO RSTTT O POCY CG Life Insurance (RBC Insurance)

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VPS 107605 122744 (01/2021)
Add a Children’s Term Rider to a Life Policy
Submit the
Critical Illness
APCTO FO RSTTT
O POCY CG
USE THIS APPLICATION FOR REINSTATEMENT OR POLICY CHANGE REQUESTS FOR:
§ Life Insurance (including requests to exchange – see page 6)
§ Disability (DI) Insurance (excluding requests for the Fundamental Series
®
– see below)
§ Critical Illness (CI) Insurance (including CI T10 to CI Level Conversions – see page 11)
§ Long Term Care (LTC) Insurance (excluding DI or CI conversions to LTC – see below)
THIS APPLICATION IS NOT TO BE USED FOR REQUESTS TO:
§ Change Banking Information
Submit a Pre-Authorized Debit Agreement
§ Increase the Death Benet on a Life Policy
Submit a New Application
§ Add a Benet and/or Rider to a Life Policy Submit a New Application
(with the exception of the children’s term rider listed below)
§ Application For Children’s Term Rider
§ Change the Beneciary Submit a Change of Beneciary Form: Life Disability
§ Exercise a Term Conversion Submit the Request to Exercise a Term Conversion Privilege
§ Change to Non-Smoker Rates on a Juvenile Policy Submit the Non-Smoker Declaration For Juvenile Policies Only
§ Preferred Class Change Submit a New Application
§ Increase the Benet Amount, Decrease the Elimination Period, or Increase The Benet Period on a Disability Policy Submit
a New Application to replace the existing coverage (internal replacement)
§ Remove a DI Policy from a Wage Loss Replacement Plan Submit the Wage Loss Replacement Plan Amendment Form –
Removal Instructions
§ Make changes to a Fundamental Series
®
Policy Submit the Application for Policy Change or Reinstatement – the Fundamental
Series
§ Increase the Benet Amount on a Critical Illness Policy Submit a New Application to replace the existing coverage (internal
replacement)
§ Convert DI or CI to LTC refer to the LTC conversion options
§ Increase disability coverage via the Future Income Option (FIO), Future Covered Expense Option (FCEO) or Future Buy-Out
Expense Option (FBEO) Submit the applicable application
Return application by mail to:
RBC Life Insurance Company, PO Box 515, Station A,
Mississauga, ON L5A 9Z9
Or return application via email as follows:
Life and LTC: customerserviceteamc@rbc.com
DI and CI: canadacallcentre@rbc.com
1-800-461-1413 www.rbcinsurance.com
®/ ™ Trademark(s) of Royal Bank of Canada. Used under licence
VPS 107605 122744 (01/2021)
TABLE OF CONTENTS
Collection and Use of Personal Information 2 ....................................................
............................................................
.............................................................
..................................................................
...........................................................
................................................................................
Consumer Fact Sheet Pre-Notice 4
Personal History Interview (PHI) 4
Client Identity Information 6
Section A: Reduction Of Coverage 6
Life 6
Critical Illness 6 ........................................................................
............................................................................
......................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................................................
Disability 7
Long Term Care 7
Section B: Reinstate A Lapsed Policy 8
Section C: Change(s) To Life Policy 8
Section D: Change(s) To Disability Policy 9 ......................................................
.................................................
.........................................................
............................................................
............................................................
Section E: Change(s) To Critical Illness Policy 11
Section F: Employment Information 12
Section G: Financial Information 12
Section H: Existing And Pending Coverages 13 ..................................................
.............................................................
.................................................
.............................................................................
...........................................................................
.....................................................................
Section I: Additional Information 13
Section J: Medical Information 15
Section K: Reinstate A Long Term Care Policy 20
Agreement 22
Authorization 24
Advisor’s Declaration 26
Page 1 of 26
VPS 107605 122744 (01/2021)
DETACH AND GIVE TO THE INSURED
COLLECTION AND USE OF PERSONAL INFORMATION
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 background;
§ 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 conrm 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,
nancial 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 benet, 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 condentiality of this information.
In the event our service provider is located outside 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 nancial 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, (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, and (iii) to let RBC companies know your choices under “Other uses of your personal information” for the sole purpose
of honouring your choices.
If we have your social insurance number, we may use it for tax related purposes and share it with the appropriate
government agencies.
Page 2 of 26
COLLECTION AND USE OF PERSONAL INFORMATION
VPS 107605 122744 (01/2021)
DETACH AND GIVE TO THE INSURED
COLLECTION AND USE OF PERSONAL INFORMATION
Please note that this paragraph is not applicable if this form is submitted by an independent representative or a representative that is attached
to a rm other than RBC Insurance
®
.
Other uses of your personal information
We may use this information to promote our products and services, and promote products and services of third parties we select, which may
be of interest to you. We may communicate with you through various channels, including telephone, computer or mail, using the contact
information you have provided.
We may also, where not prohibited by law, share this information with RBC companies for the purpose of referring you to them or promoting
to you products and services which may be of interest to you. We and RBC companies may communicate with you through various channels,
including telephone, computer or mail, using the contact information you have provided. You acknowledge that as a result of such sharing they
may advise us of those products or services provided.
If you also deal with RBC companies, we may, where not prohibited by law, consolidate this information with information they have about you
to allow us and any of them to manage your relationship with RBC companies and our business.
You understand that we and RBC companies are separate, afliated corporations. RBC companies include our afliates which are engaged in
the business of providing any one or more of the following services to the public: deposits, loans and other personal nancial services; credit,
charge and payment card services; trust and custodial services; securities and brokerage services; and insurance services.
You may choose not to have this information shared or used for any of these “Other uses” by contacting us as set out below, and
in this event, you will not be refused insurance products or services just for that reason. We will never use or share your health
information for these purposes. We will respect your choices and, as mentioned above, we may share your choices with RBC
companies for the sole purpose of honouring your choices regarding “Other uses of your personal information.”
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, to ask questions
about our privacy policies or to request that the information not be used for any or all of the purposes outlined in “Other uses of your personal
information” 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 calling us at the toll free number shown above or by visiting our website at
www.rbc.com/privacysecurity.
Page 3 of 26
VPS 107605 122744 (01/2021)
DETACH AND GIVE TO THE INSURED
CONSUMER FACT SHEET PRE-NOTICE
Information regarding your insurability and claims will be treated as condential. RBC Life Insurance Company (RBC Life) or its reinsurer(s)
may, however, make a brief report thereon to the MIB, Inc., a not-for-prot membership organization of life insurance companies, which
operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance
coverage, or a claim for benets is submitted to such a company, MIB, upon request, will supply such company with the information in its le.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your le. If you question the accuracy of the
information in MIB’s le, you may contact MIB and seek a correction.
The address of MIB’s information ofce is
MIB, Inc.,
330 University Avenue,
Toronto, Ontario,
Canada, M5G 1R7
Telephone: 416-597-0590
Website: www.mib.com
RBC Life or its reinsurer(s) may also release information in its le to other life insurance companies to whom you may apply for life or health
insurance, or to whom you submit a claim for benets.
PERSONAL HISTORY INTERVIEW (PHI)
As part of the underwriting process, you may be asked to respond to a telephone interview. The Personal History Interview (PHI) is conducted
by specially trained interviewers. The interview will take approximately 20 minutes. Since we want to conduct the interview at a time most
convenient for you, we ask you on the application whether you wish to be contacted at home or at work and the best time to call.
The questions asked by the interviewer amplify the information on your application for insurance. These questions relate to personal,
nancial and medical aspects of insurability and will form part of the contract. The answers contained in the Personal History Interview and/
or supplementary questionnaire(s) completed by you during a telephone interview and included in your contract are true and correct and
form part of your application for insurance. We also use the PHI process to gather information which may have been omitted or only partially
explained. Because of the nature of the information obtained, the PHI will only be conducted directly with you.
Any information obtained during the PHI will be kept strictly condential and will not be released to anyone without your written consent.
Your co-operation in this process is greatly appreciated and enables us to provide you with the best quality underwriting.
CONSUMER FACT SHEET PERSONAL HISTORY INTERVIEW (PHI)
Page 4 of 26
VPS 107605 122744 (01/2021)
This page has been left
blank intentionally.
Page 5 of 26
VPS 107605 122744 (01/2021)
Thursday Tuesday
Please indicate: Full exchange or Partial exchange
Indicate if the remainder is to be Retained or Terminated
APPLICATION FOR REINSTATEMENT
OR POLICY CHANGE
(LIFE, DISABILITY, CRITICAL ILLNESS, LTC)
Home Phone No.
Work Phone No.
CLIENT IDENTITY INFORMATION (COMPLETE FOR ALL REQUESTS):
Name of Insured: First / Middle / Last
Home Address Email Address
Name of Policyowner (if different than the Insured): First / Middle / Last
If the Policyowner is a company, provide the name of the company.
Policyowner Address
) )
Cell Phone No.
(
(
Indicate the best day and time for us to contact the Insured by telephone should we require a Personal History Interview:
Day: Monday Wednesday Friday Saturday
Time: 8 a.m. – 12 p.m. 12 p.m. – 4 p.m. 4 p.m. – 8 p.m.
Preferred contact phone number: Cell Home or Work
SECTION A: REDUCTION OF COVERAGE
Indicate the requested change(s) below:
LIFE: Policy number
Reduce the Death Benet from
$
to
$
Remove a Life Insured (Provide full name) First Middle
Last
Apply the Cash Value of my policy to provide REDUCED PAID UP INSURANCE according to the policy’s non-forfeiture clause.
Remove Optional Benet(s) and/or Rider(s) (Please specify)
Exchange Plan Requested:
(Not to be used for the Fundamental Series
®
)
Birthdate: Day / Month / Year
Policyowner Email Address
( )
If Partial, indicate the amount to be exchanged
$
It is understood and agreed that the beneciary on the Policy remains unchanged, unless otherwise requested by the Policy Owner .
In the province of Quebec only:
If the policy is jointly owned, what is the relationship of the Joint Owners? Spouse/Common Law Other (specify)
CRITICAL ILLNESS: Policy number
Reduce the Benet Amount from
Remove Optional Benet(s) (Please specify)
$
to
$
Page 6 of 26
VPS 107605 122744 (01/2021)
SECTION A: REDUCTION OF COVERAGE – CONTINUED
Indicate the requested change(s) below:
Policy number
to
to
(Also submit a
DISABILITY:
Reduce the Basic Monthly Benet from
Reduce the Additional Monthly Benet from
Reduce the Benet Period from
Increase the Elimination Period from
Remove Optional Benet(s) (Please specify)
$
$
days
to
to
$
$
days
Add policy to an existing Wage Loss Replacement Plan (WLRP) – No change to benet amount.
Wage Loss Replacement Plan Amendment Form, an Absolute Assignment assigning ownership of the policy to the employer, and
the applicable banking information with a Pre-Authorized Debit Agreement.
Note: Policies including the Family Compassionate Care Rider (FCCR) are not eligible to be added to a WLRP, unless the policyowner authorizes
the removal of the FCCR under “Remove Optional Benets” above.
For requests to remove a policy from a WLRP, submit the Wage Loss Replacement Plan Amendment Form – Removal Instructions.
LONG TERM CARE: Policy number
Reduce the Facility Care Daily Benet from
$
to
$
Reduce the Facility Care Benet Period from to
Reduce the Home Care Daily Benet from
$
to
$
Reduce the Home Care Benet Period from to
Increase the Facility Care Elimination Period from
days
to
days
Increase the Facility & Home Care Elimination Period from
days
to
days
Remove Optional Benet(s) (Please specify)
If the only change requested is covered in Section A, proceed to to sign and date the Agreement. page 22
If the change requested is not covered in Section A, proceed to complete the applicable pages in the remainder of this Application.
Page 7 of 26
VPS 107605 122744 (01/2021)
SECTION B: REINSTATE A LAPSED POLICY
Policy number Life Disability Critical Illness Long Term Care
Life Complete Sections F, I & J; Sign and date pages 22 & 24.
Disability Complete Sections F, G, H, I & J; Sign and date pages 22 & 24.
Critical Illness Complete Sections F, H, I & J; Sign and date pages 22 & 24.
Long Term Care Complete Section K and follow the additional instructions in that section; Sign and date pages 22 & 24.
Please indicate one of the payment options below:
A cheque for the outstanding premium has been submitted with this application.
Withdraw the outstanding premium from the existing Pre-authorized Debit Agreement for this policy upon approval of the Reinstatement.
(If there has been a change in banking, submit a Pre-Authorized Debit Agreement with this Application.)
SECTION C: CHANGE(S) TO LIFE POLICY
Policy number
Indicate the requested change(s) below and complete the additional information, section(s) and/or questionnaire(s) where indicated.
Sign and date pages 22 & 24 for all requests under Section C.
Change to Non-Smoker Rates (Complete Sections F (#1a – f), I & J; a urine specimen is required)
RECONSIDERATION OF:
Exclusion or Rating for Avocation or Sport (I refers to the Insured)
I conrm that I have not participated in since , nor do I intend to
resume participation in this activity. Submit questionnaire, if applicable)
Exclusion or Rating for Aviation
Submit Aviation Questionnaire.
Exclusion or Rating for Foreign Travel
Submit Travel Questionnaire.
Other Exclusion &/or Rating (Complete Sections F (#1a – f), I & J)
(please specify)
DEPOSIT OPTION ADDITION OR INCREASES:
Only available if RBC Growth Insurance
TM
Premium Payment Period is 20 Pay or Life Pay – To Age 100 and if Dividend Option is Paid Up Additions.
Complete Sections F (#1a – f), I & J.
Note: If the amount being requested is below the “maximum deposit option amount available with no additional underwriting” indicated on the most
recent anniversary statement, do not complete Sections F (#1a - f), I & J.
The Deposit Option is not available if any Insured is rated substandard with a at extra premium.
The Deposit Option Amount should be the same amount specied in the ‘in-force’ illustration.
How often would you like to make deposit option payments? (choose one):
One-time
$
One-time Deposit Option Amount:
Specify the amount for the one-time deposit option payment. If this request is approved and the payment is received, the maximum deposit option
allowed for future payments without evidence of insurability will be updated on the next anniversary statement. The minimum amount that may be
submitted for a single payment is $100 if the policy premium payment frequency is Monthly or $1,200 if the policy premium payment frequency is Annual.
Scheduled
$
Monthly
Deposit Option Amount:
Annual Deposit Option Amount:
$
Specify the frequency and the amount for the scheduled deposit option payments going forward. If this request is approved and the rst payment is received,
the maximum deposit option allowed for future payments will be updated on the next anniversary statement. You will be permitted to pause and restart
deposit option payments in the future up to this amount without submitting additional evidence of insurability. The minimum amount that may be submitted
for scheduled payments is $100 if the policy premium payment frequency is Monthly or $1,200 if the policy premium payment frequency is Annual.
For Monthly and Annual deposit option payments, the frequency of the scheduled deposit option payments must be the same as the frequency of policy
premium payments.
Page 8 of 26
VPS 107605 122744 (01/2021)
due to a change in occupation
via upgrade criteria (can be upgraded by one class only)
Submit proof of income for the last 2 years
SECTION D: CHANGE(S) TO DISABILITY POLICY
Policy number
Indicate the requested change(s) below and complete the additional information, section(s) and/or questionnaire(s) where indicated.
Sign and date pages 22 & 24 for all requests under Section D.
Change to Non-Smoker Rates (Complete Section J)
RECONSIDERATION OF:
Exclusion or Rating for Avocation or Sport (I refers to the Insured)
I conrm that I have not participated in since , nor do I intend to
resume participation in this activity. Submit questionnaire, if applicable)
Exclusion or Rating for Aviation
Submit Aviation Questionnaire.
Exclusion or Rating for Foreign Travel
Submit Travel Questionnaire. Also submit proof of Permanent Resident Status or Canadian Citizenship if the exclusion was applied to the policy
due to the lack of either status.
Other Exclusion &/or Rating (Complete Sections F (#1a – f), I & J, and submit questionnaire, if applicable)
(Please specify)
OCCUPATION RECLASSIFICATION
Occupation reclassication to Class 4A
or
Occupation reclassication
3A 2A A
to Class 4A 3A 2A
If requesting occupation reclassication within the rst two years of the policy issue date (Complete Sections F (#1a – e) & #2a & G)
If requesting occupation reclassication greater than 2 years, up to 5 years from the policy issue date (Complete Sections F (#1a – e) & #2a, G,
I & J)
Add Health Care Professional Rider (Complete Section J) (Your refers to the Insured)
What is Your occupation?
Page 9 of 26
VPS 107605 122744 (01/2021)
SECTION D: CHANGE(S) TO DISABILITY POLICY – CONTINUED
Accidental Death and Dismemberment (AD&D)
*Beneciary Name
*All designations are revocable, except in Quebec, where the designation of a legally married spouse is irrevocable unless expressly stated to be
revocable by checking the following box.
Addition of the Optional Benets listed below, over 2 years from the policy issue date, and/or addition of Optional Benets that are
not listed below, are only available as an internal replacement (submission of a new Application to replace the existing coverage).
Addition of Optional Benet(s) – (only available within the rst 2 years
of the policy issue date) (Complete Sections F, G, I & J)
Cost of Living Adjustment (COLA)
Enhanced Denition of Disability (EDD) (Foundation Series)
Regular Occupation Extension (Bridge Series)
First Day of Hospitalization
Hospitalization (Bridge Series)
Partial Disability Benet:
Short-Term Partial – indicate number of months
or
Long-Term Partial – indicate number of years
6 12 or 24
5 10 or To age 65
Benet Requested
$
*Beneciary of the AD&D benet (only required if applying to add the AD&D benet).
If no beneciary designation is provided, benets will be payable to the estate of the insured.
Relationship to the Insured
Revocable
* Except in the Province of Quebec, if you have designated a beneciary who is a minor (under the age of 18), a trustee should be named in
order to avoid payment of the proceeds into court. In Quebec, benets payable to minors are paid to the surviving parent(s) as tutor(s).
Name of Trustee Relationship to the Insured
Page 10 of 26
VPS 107605 122744 (01/2021)
Amount to be converted
Do You currently have a pending or payable claim for Critical Illness benets, or are You currently satisfying a survival
period for Critical Illness on this policy?
SECTION E: CHANGE(S) TO CRITICAL ILLNESS POLICY
Policy number
Indicate the requested change(s) below and complete the additional information, section(s) and/or questionnaire(s) where indicated.
Sign and date pages 22 & 24 for all requests under Section E.
Change to Non-Smoker rates (Complete Section J)
RECONSIDERATION OF:
Exclusion or Rating for Avocation or Sport (I refers to the Insured)
I conrm that I have not participated in since , nor do I intend to
resume participation in this activity. Submit questionnaire, if applicable)
Exclusion or Rating for Aviation
Submit Aviation Questionnaire.
Exclusion or Rating for Foreign Travel
Submit
Travel Questionnaire. Also submit proof of Permanent Resident Status or Canadian Citizenship if the exclusion was applied to the policy
due to the lack of either status.
Other Exclusion &/or Rating (Complete Sections F (#1a – f), I & J and submit questionnaire, if applicable)
(please specify)
Addition of Optional Benet
Disability Waiver of Premium Rider – (only available within the rst 2 years of the policy issue date) (Complete Section J)
Addition of the Disability Waiver of Premium Rider over 2 years from the policy issue date, and/or addition of any other Optional
Benets, is only available as an internal replacement (submission of a new Application to replace the existing coverage).
Convert 10-year term (T10NC) to level premium CI policy (You refers to the Insured)
1. Are premiums under the disability waiver of premium rider on this policy or under the provisions of an income
replacement policy issued by RBC Life Insurance currently being waived? ......................................... Yes No
2.
.................................................................... Yes No
If You answered “Yes” to either of the questions above, conversion is not available.
If You answered “No” to the questions above, please indicate the requested change below.
Total conversion to NC75 , GR65 , or GR75
Partial conversion to NC75 , GR65 , or GR75
$
Page 11 of 26
VPS 107605 122744 (01/2021)
SECTION F: EMPLOYMENT INFORMATION (You/Your refers to the Insured)
1. a. Are You currently employed? ...............Y es No
b. What % of time is spent working in Your home?
b. Occupation
c. Is employment seasonal?..................Y es No
c. Business/Employer Name
d. If Yes, how many weeks worked per year?
d. Describe Your duties:
3.
Are You eligible for:
e. How long have You been in Your current occupation?
a. Employment Insurance?...................Y es No
f. How many hours per week do You currently work?
b. W
orkers’ compensation benets
(e.g. WSIB/WCB, CNESST)?...............Y es No
Also answer questions #2 a-d and #3 a-c for requests to reinstate
Disability policies:
c. CCQ for Disability Coverage? ..............Y es No
2. a. Professional Designation(s) or Degree(s)
SECTION G: FINANCIAL INFORMATION (You/Your Refers To The Insured)
Net earned income is Your income after all business expenses, before personal taxes. Do not include other sources of income such as EI benets,
retirement benets, family allowance or any income which is not dependent on Your ability to work. Do NOT include PERKS. They will be included
in the calculations at our ofce if the Insured is eligible.
1. a.
What was Your net annual earned income as declared on Your federal income tax return for the last TWO calendar years?
Calendar Year Amount
$
$
b.
If You are a shareholder of the Corporation You work in, what was Your share of the net income for the last TWO scal years?
Calendar Year Amount
$
$
c.
If You are an employee, what is Your current annual salary?
$
Page 12 of 26
VPS 107605 122744 (01/2021)
1. In the past 24 months, have You engaged in any hazardous or contact sports or activities, including but not limited to racing,
scuba diving deeper than 100ft (30m), skydiving, heli-skiing or back-country skiing, or do You intend to do so?
SECTION H: EXISTING AND PENDING COVERAGES
1. For Reinstatement of a:
Disability policy Describe all disability coverages in force and pending, including any with RBC.
Critical Illness policy Describe all critical illness coverages in force and pending, including any with RBC.
For all of the above List the specics under (A) Individual, (B) Association, (C) Group LTD, (D) Salary Continuation or Employer Sick Pay
Disability Income Coverage, (E) Overhead Expense, (F) Buy Sell, (G) Key Person, (H) Business Loan, (J) Accident Only,
(K) Government Plans, (L) Critical Illness, or (O) Other.
Specify (O) Other
If none, write “None.”
DI Only
Name of Insurance Company
Amount and Type of Insurance
(Life, CI or Disability)
(A, B, C, D, etc.)
Year and
Month Issued
Elimination
Period
Benet
Period
Taxable
Yes No
$
Type
Policy #
$
Type
Policy #
$
Type
Policy #
$
Type
Policy #
SECTION I: ADDITIONAL INFORMATION (You/Your refers to the Insured)
.................... Yes No
If Yes, provide details or complete the appropriate questionnaire.
Hazardous or Contact Sport or Activity Type Dates, Frequency, Professional/Amateur, Recreational/Commercial
Page 13 of 26
VPS 107605 122744 (01/2021)
If Yes, please complete the
SECTION I: ADDITIONAL INFORMATION – CONTINUED (You/Your refers to the Insured)
2. In the past 12 months, have You traveled outside Canada or the United States of America, or do You intend to do so
within the next 12 months?
6.
Been convicted of any driving offences or violations, including impaired driving, and/or have You had a driver’s license revoked
or suspended, or are any such charges pending?
...................................................................................... Yes No
If Yes, provide full details, including countries and cities, length of stay in each country, and the reason for the visit;
or complete the Travel Questionnaire
Details
Since the date of the original Application, have You:
3. Flown an aircraft as a pilot or student pilot, or operated as a crew member, or do You intend to do so? ........................... Yes No
Aviation Questionnaire.
4. Had life, disability or critical illness insurance rejected, rated, modied, rescinded, or have You been denied renewal or reinstatement?.... Yes No
If Yes, provide details.
Indicate Type of
Insurance
Rejected Rated Modied Rescinded
Denied Renewal or
Reinstatement
Insurer Reason
5. Received disciplinary action from Your licensing body and/or been found guilty of a criminal offence, or are criminal
charges pending? ............................................................................................. Yes
No
If Yes, provide details.
Date of Incident Details Including Outcome
.................................................................... Yes
No
If Yes, provide the driver’s license number and complete details below, including dates, offence type, how many km/h over the limit.
Driver’s License Number Details, Dates, Offense Type(s), km/h Over Limit
7. Declared personal or corporate bankruptcy or led any form of Proposal? ................................................. Yes
No
If Yes, provide the discharge date and complete details below.
Date of Discharge or
Proposal
Complete Details
Page 14 of 26
VPS 107605 122744 (01/2021)
4. Have You had any symptoms or complaints regarding Your health for which You have not yet consulted a physician
or received treatment?
8. In the past 24 months have
You used cigarettes, e-cigarettes, vaping products, cigars, water pipes, betel nut, smoking
cessation products or nicotine or tobacco in any form?
!
SECTION J: MEDICAL INFORMATION (You/Your refers to the Insured)
When answering the questions on this form, DO NOT provide information about any genetic test You have taken or plan to take. A genetic test is a type of
medical test which analyzes DNA, RNA, or chromosomes. DO provide information about other types of medical tests.
1. Current Height cm ft/in Current Weight kg lb
2. In the past 12 months, have You lost 10lb/5kg or more? ............................................................... Yes No
If Yes
Reason Amount Lost
kg lb
3. Are You presently under medical observation or investigation, treatment, therapy, counselling or taking medication? ............... Yes No
Details
Name of Medication Dose Amount Frequency Taken Date Started
......................................................................................... Yes
No
Details
5.
Who is Your family physician or regular healthcare provider or clinic?
Provide the full address and phone number.
(If none, write “None.”)
6. Provide the name of the healthcare provider who has Your most recent health record if different from Your regular healthcare provider or clinic.
7. Provide the date and reason for Your last consultation with ANY physician or healthcare provider, the name of the provider, and the outcome/results.
................................................................ Yes
No
Details/Product Type
(cigars, cigarettes, “vaping” etc.)
Quantity &
Frequency of use
Date Last
Used
Details of Smoking Cessation Therapy (type, date last used)
Details include symptoms, date of onset, diagnosis, treatment, date of full recovery and name of health care provider.
Page 15 of 26
VPS 107605 122744 (01/2021)
10. Do You consume alcoholic beverages?
!
SECTION J: MEDICAL INFORMATION – CONTINUED (You/Your refers to the Insured)
9. Have You used marijuana and/or hashish within the past 5 years? ...................................................... Yes No
If Yes, indicate the quantity and frequency of use, and date last used.
............................................................................ Yes No
If Yes, provide details.
Amount
Day Week Month Year
Beer cans/bottles
Wine glasses
Liquor ml/oz
Since the date of the original Application, have You:
11.
Sought or received advice or treatment relating to alcohol use, or used alcohol excessively?................................... Yes
No
If Yes, please complete the Alcohol Use Questionnaire.
12. Used cocaine, barbiturates, crack, or any other narcotic drug, or sought or received advice or treatment for the use of drugs,
prescribed or non-prescribed? ................................................................................... Yes
No
If Yes, please complete the Drug Use Questionnaire.
13. Been absent from work for 15 consecutive days or more for any injury and/or illness? ........................................ Yes No
Details
Since the date of the original Application, have You had any known indication of or been treated for:
14
a.
AIDS, a positive or unknown HIV test result, or any other disorder of the immune system? ................................ Yes
No
Details
b.
Any disease or disorder of the eyes, ears, nose or throat (including loss of speech)? ..................................... Yes
No
Details
c. Sleep apnea, chronic insomnia, or any other sleep disorder? ....................................................... Yes
No
Details
d. Chest pain, heart attack, angina, abnormal ECG, irregular pulse, heart murmur , high blood pressure, high cholesterol,
peripheral vascular disease or any disease or disorder of the heart or circulatory system?................................. Yes
No
Details
Details include symptoms, date of onset, diagnosis, treatment, date of full recovery and name of health care provider.
Page 16 of 26
VPS 107605 122744 (01/2021)
!
Stroke, transient ischemic attack (TIA), headaches, cognitive impairment, memory problems, Parkinson’s disease,
Alzheimer’s disease, motor neuron disease, Huntington’s disease, ALS, fainting spells, dizziness, seizures,
epilepsy, paralysis, multiple sclerosis, muscle weakness, numbness or tingling of the limbs, or any disease or
disorder of the brain or nervous system?
Protein, albumin, blood, or sugar in the urine, abnormal prostate test, kidney stones, or any disease or disorder of the kidneys,
urinary tract, bladder, prostate, or reproductive organs?
Anxiety, depression, nervousness, stress, fatigue, burnout, eating disorder, other emotional disorder, psychiatric disorder,
mental disorder or psychosis; or have You attempted suicide?
Cancer, dysplastic nevi, tumour, cyst, mass, lesion, lump, nodule, polyp or other growth, any disorder of the skin or lymph
glands, blood disorder or any form of malignant disease?
Any disease or disorder of the breast, including lumps, cysts or other masses, other physical changes,
abnormal mammogram ndings or any biopsy?
SECTION J: MEDICAL INFORMATION – CONTINUED (You/Your refers to the Insured)
Since the date of the original Application, have You had any known indication of or been treated for:
e.
....................................................................... Yes No
Details
f.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
Details
g.
...................................................... Yes
No
If Yes, please provide details or complete the Mental Health Questionnaire.
Details
h. Chronic fatigue, chronic fatigue syndrome, Epstein-Barr virus, bromyalgia, or chronic pain? .............................. Yes
No
Details
i.
.......................................................... Yes
No
Details
j. Diabetes, elevated blood sugar, thyroid disease, rheumatism, rheumatic fever, lupus, gout, or syphilis? ...................... Yes
No
Details
k. Work-related allergies, environmental hypersensitivity or illness, or non-seasonal allergies? ............................... Yes
No
Details
l.
.................................................................. Yes
No
Details
Details include symptoms, date of onset, diagnosis, treatment, date of full recovery and name of health care provider.
Page 17 of 26
VPS 107605 122744 (01/2021)
!
Any type of asthma, emphysema, COPD, chronic bronchitis, pleurisy, pneumonia, tuberculosis, or any disease or disorder
of the chest or lungs?
SECTION J: MEDICAL INFORMATION – CONTINUED (You/Your refers to the Insured)
Since the date of the original Application, have You had any known indication of or been treated for:
m. Any amputation or deformity, hernia or rupture, deep vein thrombosis or varicose veins?.................................. Yes No
Details
n. Any arthritis, disease or disorder of the hip, ankle, knee, wrist, elbow, shoulder, hands, feet or any other joint?................. Yes
No
If Yes, which joint(s)? Right
Left Both
Details
o. Any type of back or spinal trouble (includes neck area) including sprain, strain, or disc disease or disorder?................... Yes
No
If Yes, please provide details or complete the Back and Neck Disorder Questionnaire.
Details
p.
...................................................................................... Yes
No
Details
q. Any type of peptic ulcer, indigestion, colitis, or any disease or disorder of the stomach, colon or intestines, gall bladder, liver,
pancreas; or have You tested positive for hepatitis and/or been told You are a carrier? ................................... Yes
No
Details
Since the date of the original Application, have You:
15. a.
Been examined by or consulted a physician, chiropractor
, psychologist, physiotherapist, osteopath, homeopath,
or other practitioner? ............................................................... ........................ Yes
No
Details
b. Been under observation or treatment in any hospital or other institution or facility, or been advised to be admitted? ............. Yes
No
Details
c. Had an X-ray, ECG, CT scan, MRI, blood or urine test, or other diagnostic tests?........................................ Yes
No
Details
Details include symptoms, date of onset, diagnosis, treatment, date of full recovery and name of health care provider.
Page 18 of 26
VPS 107605 122744 (01/2021)
SECTION J: MEDICAL INFORMATION – CONTINUED (You/Your refers to the Insured)
Since the date of the original Application, have You:
Since the date of the original application,
have You experienced any complications with this pregnancy or any past pregnancy?
d. Had any surgical operation, treatment, special diet, or any illness, ailment, abnormality or injury? ........................... Yes No
Details
e. Been advised to have any diagnostic test, hospitalization, or surgery which was not completed?............................ Yes
No
Details
Since the date of the original Application:
16.
Have Your natural parents, brothers or sisters, either living or dead, suffered from any of the following conditions:
heart disease, polycystic kidney disease, high blood pressure, a stroke, diabetes, cancer, multiple sclerosis, Alzheimer’s disease,
Huntington’s disease, Parkinson’s disease, motor neuron disease or any form of hereditary disease?............................ Yes
No
If Yes, complete the chart below.
Condition Mother
Age at
Onset
Father
Age at
Onset
Sister
Age at
Onset
Brother
Age at
Onset
Female Applicants Only
17.
Are You currently pregnant? ............................................................... ...................... Yes No
If Yes,
a. What is the due date?
b.
................................ Yes No
If Yes, provide details.
As needed, provide additional details below to any Yes answers from Section J.
Question
Number
Conditions, Symptoms, Diagnosis and Treatment
Date of
Onset
Name of Healthcare Provider
Date of
Recovery
Page 19 of 26
VPS 107605 122744 (01/2021)
Do You currently need, or within the past 5 years have You required another person’s help in performing any activities of daily
living such as bathing, dressing, toileting, eating, transferring from bed to chair, controlling bladder or bowel function?
SECTION K: REINSTATE A LONG TERM CARE POLICY (You/Your refers to the Insured)
Please answer “Yes” or “No” only. Do not provide any details.
1. Are You presently:
a) Conned to a hospital or nursing home?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
b) Bedridden, wheelchair conned or in need of home nursing or health aid services? ...................................... Yes No
c) Receiving physical, speech, or inhalation therapy, or kidney dialysis? ................................................. Yes No
2. Are You presently being treated, or within the past 5 years have You been treated or advised to be treated for:
a) Multiple Sclerosis, leukemia or liver cirrhosis? ...................................................................Yes
No
b) Senility, dementia, brain disease or disorder, Alzheimer’s, Parkinson’s disease, ALS, or other motor neuron disease? ........... Yes No
c) A lung disorder which requires the use of oxygen or a mechanical device to help You breathe?............................. Yes No
d) Insulin dependent diabetes mellitus, retinopathy, stroke or paralysis? ................................................. Yes No
e) AIDS or other immune system disorder? ....................................................................... Yes No
3. Since the date of the original Application, have You:
a) Been advised to have joint replacement or other surgery which has not been done? ..................................... Yes
No
b) Been advised You need hospitalization, nursing home care, home health care or kidney dialysis?........................... Yes No
c) Had, or been advised to have an amputation because of a medical condition? .......................................... Yes No
...............
4.
Yes No
If You answered “Yes” to any of the questions above,
reinstatement of Long Term Care coverage is not available.
Do not submit an application.
If You answered “No” to all of the questions above, complete Section J,
answer question #5 below, and sign and date pages 22 & 24.
5. Do You intend to reside or travel outside of Canada or the United States of America? ........................................ Yes No
If Yes, provide full details, including countries and cities, length of stay in each country, and the reason for the
visit; or complete the Travel Questionnaire.
Details
Page 20 of 26
VPS 107605 122744 (01/2021)
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Page 21 of 26
VPS 107605 122744 (01/2021)
AGREEMENT
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 benets,
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
void.
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 ofcer of the Company may (a) alter or modify the terms of this Application or Policy or (b) waive any rights or requirements of
the Company.
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 satised 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, Benets or Classication unless agreed to in writing by the
Owner.
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 notication, 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
terms.
14. I understand that the Company will create and maintain at their ofce 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 rectied 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.
AGREEMENT
Signed at this
(City/Province)
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)
day of
(Month/Year)
Signature of Irrevocable or Preferred Beneciary (if applicable)
Signature of Joint Owner (if applicable)
If Corporate Owner, provide the title of signing ofcer. If Trustee Owner, identify
the Trust.
* In Quebec, if there is more than one tutor
, all tutors must sign unless one tutor has been given the authority in a specic 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 Ofcer of the corporation other than the Insured
(unless the Insured is the sole Ofcer of the corporation).
Page 22 of 26
VPS 107605 122744 (01/2021)
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Page 23 of 26
VPS 107605 122744 (01/2021)
AUTHORIZATION
Name of Insured:
I understand and authorize the Company (RBC Life Insurance Company and its reinsurers) to conduct such investigation as is necessary and
to gather personal information concerning me and/or my child (as named above). I understand that the Company will create and maintain les
that contain personal information concerning me and/or my child. I also understand that access to personal information concerning me and/or my
child will be limited to the employees of, and other persons engaged by, the Company in performance of their duties, or to the persons to whom
I have granted access, in writing, or to any other person authorized by law. I further understand that, except when the Company can and does
lawfully restrict my access to personal information concerning me and/or my child, 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 to have any errors in the personal information noted and corrected by formulating a written request
to the Company. 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 and/or my child, my and/or my child’s medical history or treatment, or my and/or my child’s past
and present income or employment that is relevant to this application that they have in their possession or control.
Persons to whom this Authorization applies: Any licensed physician, nurse, counselor, psychologist, social worker, therapist, 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 or reinsurance company or
other nancial institution; and also my and/or my child’s employer or former employers; and also any federal or provincial government department
or organization, including the federal or provincial income tax authorities and provincial motor vehicle divisions; and also the MIB, Inc.; and also
any other person, agency, credit bureau or institution having information, records or data regarding me and/or my child. This Authorization to
obtain information is valid until revoked by me in writing. If I choose to revoke this Authorization to obtain information, consequences may include
termination of the underwriting process and/or the policy, if one has been issued.
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 assessment of insurance risk for underwriting purposes; for the purpose of evaluating any claim for benets; assessing the validity of
the policy as issued; and, issuing and delivering the policy. Only to the extent reasonably necessary for those purposes, I authorize the Company
to disclose any of the said information, records or data received: to the MIB, Inc.; to other insurance companies, or any reinsurer; and, to my
Servicing Representative, such as my insurance advisor or broker. This Authorization to disclose information as reasonably necessary is valid until
revoked by me in writing.
I authorize the Company to disclose to my Servicing Representative material information regarding my and/or my child’s health and personal
history solely for the purpose of explaining underwriting decisions. This disclosure could include history of mental illness, infectious disease, drug
and alcohol use, record of criminal activity, or other facts that have a material effect on the Company’s decision to insure me and/or my child.
This Authorization to disclose information for this purpose is valid until 60 days after the later of the day the Company issues a new or amends
the existing policy; or the day the Company noties me in writing that my and/or my child’s application has been declined, withdrawn, or led as
incomplete.
I do not agree to the disclosure of health and personal information to the Servicing Representative:
I also authorize the Company to release to my and/or my child’s health care professional any medical information obtained for this insurance
application, including the results of any blood or urine test or urine drug screening tests for the purpose of revealing ndings that might require
further investigation or treatment or for the purpose of explaining any underwriting decision. This Authorization to disclose medical information
is valid until revoked by me in writing. A photocopy of this Authorization, as executed by me, will be as valid as the original. Any alteration of this
Authorization will render it null and void.
Signed at this day of Year
City/Province Month
AUTHORIZATION
Signature of Insured or Parents/Guardians (tutors in Quebec) if Insured
is under age 16 years (under age 18 years in Quebec).
*
*
In Quebec, if there is more than one tutor, all tutors must sign unless one tutor has been given the authority in a specic mandate to act
unilaterally on the child’s behalf.
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VPS 107605 122744 (01/2021)
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Page 25 of 26
VPS 107605 122744 (01/2021)
ADVISOR’S DECLARATION
I have clearly explained the provisions and limitations of the policy change or reinstatement being applied for to the Insured and the Owner(s). All of
the questions in the application were clearly asked of, or read by, the Insured and the Owner(s). To the best of my knowledge, they understood all of
the questions. To the best of my knowledge, all of the answers and statements on the application have been fully and accurately recorded. I am not
aware of any pertinent
information about the Insured that has not been disclosed on the application.
Date (dd/mm/yyyy)
Advisor’s Signature
Advisor’s Name
Advisor’s Company Name
Marketing Ofce
Please use this space for any special instructions or additional information which would be helpful in the underwriting of this risk.
Page 26 of 26
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APCTO FO RSTTT O POCY CG Life Insurance (RBC Insurance)

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Completed 21 May 2021

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