Fill - Free fillable Change of Name 1. Form must be completed (RBC Insurance) PDF form

VPS 107283 Page 1 of 3

00441 (07/2020)

INSTRUCTIONS:

1. Form must be completed in duplicate.

2. An endorsed copy will be returned for your records, as it forms part of your policy document.

3. Before returning, please check that the appropriate section is fully completed and the signatures have been witnessed

and dated.

RBC Life Insurance Company is requested and authorized to make the changes below, regarding:

Policy Number

Life Insured(s)

Policyowner(s)

CHANGE NAME OF

Policyowner to:

Life insured to:

Beneciary to:

Reason for change: ATTACH ORIGINAL OR NOTARIZED COPIES OF LEGAL DOCUMENTS

 Marriage (state date)  Divorce (state date)

 Error (explain)

 Court Order (explain)

SIGNATURE OF POLICYOWNER DATE

ENDORSEMENT

For Ofce Use Only

While this form has been prepared for the convenience of its policyholders, the Company assumes no responsibility for its validity or

sufciency.

RECORDED AT THE HEAD OFFICE OF RBC LIFE INSURANCE COMPANY

ON BY

Mississauga Ofce: 6880 Financial Drive, West Tower, Mississauga, Ontario, L5N 7Y5 ~ 905-606-1000

Change of Name

click to sign

signature

click to edit

VPS 107283 Page 2 of 3

00441 (07/2020)

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 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 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.

VPS 107283 Page 3 of 3

00441 (07/2020)

® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.

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 asking for a copy of our “Straight Talk®” brochure

about privacy, by calling us at the toll free number shown above or by visiting our web site at www.rbc.com/privacy.

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