73530 (05/2009)
Application for Accident Insurance Conversion
RBC LIFE INSURANCE COMPANY
PO BOX 1800 STN B, MISSISSAUGA, ON L4Y 3W6
(ID CUSTOMER SERVICE)
Person to
Be Insured
Name (Last, First, Middle Initial) Date of Birth (month/day/year) Gender
Male Female
Number Street
Address
City Province Postal Code
Occupation
Occupation Duties
Employer's
Name and
Address
Employer’s Name and Address
Beneficiary
Beneficiary Name (Last, First, Middle Initial) Relationship to Insured
(If Spouse and/or Children are covered, their beneficiary is the Insured)
Is the policy being applied for to replace any similar insurance You now have?
No Yes (If "Yes", please furnish names of companies and amounts)
24-Hour Accident Insurance
Insured Insured & Family Insured and Children Principal Sum: $
Name of Family Member Relationship Birth Date (Mo/Day/Yr)
INFORMATION STATEMENT: For policies of this type, RBC Life Insurance Company anticipates that 50% of the premiums will be required for
claims. This is not a contractual obligation.
I declare that the recorded answers to the questions on this application are to the best of my knowledge and belief full, complete and
true. RBC Life Insurance
Company is not bound by any statements made by or to the agent unless such statements are written in this application.
Signature of Applicant:
Date:
FOR COMPANY USE ONLY
Policy No. HVA
Term 12 months
Term Premium $
Effective Date of Coverage: First Renewal Premium Due: $
® Registered trademarks of Royal Bank of Canada. Used under licence.
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signature
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