Fillable Application for Childrens Term Rider to RBC Life

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Application for Childrens Term Rider to RBC Life

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Application for
Children’s Term Rider
to RBC Life Insurance Company
Must be the natural or adopted child of a Life Insured named in the Life Insurance Application.
RBC Life Insurance Company (RBC Life) recommends the appointment of a Contingent Owner if the Proposed Insured is also the Proposed
Owner.
All children must be between 14 days and 20 years of age.
Any child age 16 or over, or age 18 or over in Quebec, must sign the application.
The beneficiary for this benefit will be the Proposed Insured or Proposed Joint Insureds under the policy.
Su
pp
lement to Polic
y
Number
(
if known
)
or A
pp
lication number
Benefit Amount $
Children’s Names
(a) First Name Middle Name Last Name
Female Male Date of Birth (dd/mm/yy) Age as of Nearest Birthday
Height cm ft/in Weight kg lb Relationship to Proposed Insured(s)
Relationship to Proposed Owner
(b) First Name Middle Name Last Name
Female Male Date of Birth (dd/mm/yy) Age as of Nearest Birthday
Height cm ft/in Weight kg lb Relationship to Proposed Insured(s)
Relationship to Proposed Owner
(c) First Name Middle Name Last Name
Female Male Date of Birth (dd/mm/yy) Age as of Nearest Birthday
Height cm ft/in Weight kg lb Relationship to Proposed Insured(s)
Relationship to Proposed Owner
Children’s Medical History
Yes No
1. Has any insurance application on any child been declined, postponed or modified in any way?
2. Do any of the children have any physical or mental impairment or have they had any illness, impairment or injury that has
required treatment or an operation?
3. Are any of the children currently on medication or has any treatment or diagnostic test been advised that has not been
completed?
4. Do all of the above children reside with the Proposed Insured? If no, provide details below about who the child lives with and
how often the Proposed Insured sees the child.
5.
What was the reason for, the date of and the result of the child’s last visit to a health care professional? Please answer below and include
health care professional’s name, professional designation, address, postal code and phone number.
Child Question # Details
(04/2020) Policy Administration
Page 1 of 4
Children’s Term Rider Declarations and Authorizations
I certify that to the best of my knowledge the answers given are full, complete and true and agree that they shall form part of my Life Insurance
Application to RBC Life.
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 on the Application for Children’s Term Rider attached hereto). I understand that the
Company will create and maintain files, which 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 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 mailed to the employee who is handling my Application.
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, which 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
financial 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 to any
other person, agency, credit bureau or institution having information, records or data regarding me and/or my child.
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 and for the purpose of evaluating any claim for benefits or to assess the validity of the
policy as issued.
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., and to other insurance companies or any reinsurer.
This authorization is valid until revoked by me in writing.
A photocopy of this authorization, as executed by me, will be as valid as the original.
Dated at this day of Year
City/Province
Signature of parent/guardian* Signature of parent/guardian*
Signature of any child age 16 or over, or age 18 or over in Quebec Signature of any child age 16 or over, or age 18 or over in Quebec.
Signature of Owner (if other than parent/guardian) Signature of Joint Owner (if any)
*In Quebec, both parents/guardians must sign unless one parent/guardian has given the other a specific mandate to act unilaterally on the child’s
behalf.
(04/2020) Policy Administration
Page 2 of 4
Signature of parent/guardian*
Signature of any child age 16 or over, or age 18 or over in Quebec
Signature of Owner (if other than parent/guardian)
THE FOLLOWING PAGES ARE TO BE LEFT WITH THE POLICY OWNER
Notice regarding the MIB, Inc.
Information regarding your insurability will be treated as confidential. RBC Life Insurance Company or its reinsurers may, however,
make a brief report to the MIB, Inc., a non-profit 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 benefits is submitted to such company, MIB, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. If you question the
accuracy of the information in MIB’s file, you may contact MIB and seek a correction. The address of MIB’s information office is:
MIB, Inc., 330 University Avenue, Toronto, Ontario, CANADA M5G 1R7 Telephone: (416) 597 - 0590. Web site:
http://www.mib.com
RBC Life Insurance Company or its reinsurers may also release information in its file to other life insurance companies to whom you
may apply for life or health insurance or to whom a claim for benefits may be submitted.
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 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.
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, (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.
(04/2020) Policy Administration
Page 3 of 4
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 firm 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, affiliated corporations. RBC companies include our affiliates which are
engaged in the business of providing any one or more of the following services to the public: deposits, loans and other personal
financial 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 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/privacysecurity.
®
Registered trademarks of Royal Bank of Canada. Used under license.
(04/2020) Policy Administration
Page 4 of 4
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Application for Childrens Term Rider to RBC Life

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Completed 30 September 2020

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