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4. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this cancer:
Physician/Hospital Address and Telephone Dates seen
Has your patient previously suffered from cancer or any predisposing disorders?
o If “Yes,” please provide dates and details:
b) Has your patient ever been tested for the Human Immunodeciency Virus?
Date: (DD/MM/YYYY) Result:
a) Is there a family history of cancer?
Please provide details:
b) Please provide details of any other signicant family history:
a) Please provide details of your patient’s past and present tobacco use, including amount per day and date last used:
b) Please provide details of your patient’s past and present use of any smoking cessation products, including amount per day and date last used:
Please provide any other information that would be helpful in the assessment of your patient’s claim:
Our contract requires that a covered illness be diagnosed by a physician who is not related to or in a business relationship with the insured. Are you related to or in a
business relationship with this patient?
Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name Primary Care Consultant
(Street / City / Province / Postal Code)
Telephone No. Fax No.
Send the completed form and documents to our ofce by email: email@example.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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