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00441 (07/2020)
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 to:
Life insured to:
Beneciary to:
Marriage (state date) Divorce (state date)
Error (explain)
Court Order (explain)
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
Mississauga Ofce: 6880 Financial Drive, West Tower, Mississauga, Ontario, L5N 7Y5 ~ 905-606-1000
Change of Name
click to sign
click to edit
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00441 (07/2020)
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
If we have your social insurance number, we may use it for tax related purposes and share it with the
appropriate government agencies.
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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.