Change of Name
1. This form is to be used to change the name of the Certificate holder, Spouse or Beneficiary on Personal Accident
Protection certificates.
2. Before returning, please check that the appropriate section is fully completed and the signatures have been
witnessed and dated.
3. This form must be accompanied with copies of legal documents.
4. This change will not be effective until recorded at our office. Once recorded, the change will be effective as of
the date you signed the request. We will then send you an updated Certificate of Insurance.
RBC Life Insurance Company is requested and authorized to make the changes below, regarding policy #
AC4138PH and # AC4140PH:
Certificate Holder Name:
Certificate Number:
Certificate Holder to:
Spouse to:
Beneficiary to:
(state date) ________________________ Divorce (state date)______________________________
Re-married - My new spouse resides in Canada for at least six months of each calendar year: Yes No
Error (please explain)
Other (please explain)
Signature of Certificate Holder Date: mm/dd/yyyy
Signature of Witness Date: mm/dd/yyyy
Office Use Only
_________DAY OF___________________20__________ BY:___________________________
RBC Life Insurance Company
Policy Accounting
P.O. Box 515, Station A, Mississauga, ON, L5A 9A9
® Registered Trademarks of Royal Bank of Canada. Used under licence.
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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 ha
ve your social insurance number, we may use it for tax related purposes and share it with the
appropriate government agencies.
Other uses of your 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 firm other than RBC Insurance
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
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