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Has there been any improvement in the patient’s speech since the onset of the condition?
What investigations or tests have been performed to verify the diagnosis of permanent loss of speech?
8. Has your patient suffered any previous episodes of loss of speech or any condition leading to or related to it?
9. Please provide the names and addresses of other physicians or speech language therapists consulted, or hospitals attended by your patient for this
Physician/Hospital Address and Telephone Dates seen
10. Please provide details of any signicant family history:
11. 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:
12. 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? Yes
Signature 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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