P.O. BOX 1614
WINDSOR, ONTARIO N9A 0B9
Customer Service Centre 1-855-264-2174
DENTAL ACCIDENT REPORT FORM
PATIENT
NAME:
PLAN MEMBER ID:
RELATIONSHIP TO PLAN MEMBER:
EMAIL ADDRESS:
ADDRESS:
PHONE NUMBER:
CITY/PROV/POSTAL CODE:
( )
MANDATORY DECLARATION
Do you have any other group insurance coverage that may include these services as benefits? Yes No
If yes, insurance company name:
If other coverage is RBC Life, indicate Plan Member ID:
Is treatment required due to a motor vehicle accident? Yes No
Is treatment required due to a work-related injury? Yes No
DATE OF ACCIDENT PROVINCE/STATE/COUNTRY LOCATION OF ACCIDENT
/ /
DAY MONTH
DESCRIBE BRIEFLY HOW THE ACCIDENT OCCURRED
YEAR
I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT OF THIS CLAIM TO THE INSURER/PLAN
ADMINISTRATOR AND CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
/ /
DAY MONTH YEAR PLAN MEMBER'S SIGNATURE
DENTIST (TO BE COMPLETED BY THE TREATING DENTIST)
DENTIST'S SIGNATURE
UNIQUE NO.:
/ /
NAME:
DAY MONTH YEAR
ADDRESS:
By signing this claim form and/or submitting actual receipts, I agree that the
information provided on this form is complete and accurate. I understand
that the information provided by me to RBC Life about myself and my
dependents, will be used by RBC Life for claims adjudication and any other
services necessary in the administration of our benefits which may include
the exchange of information with other parties to administer this benefit claim.
I am authorized by my spouse and/or dependents to disclose and receive
information about them that is used for these purposes. I understand that
this information may be seen by the insured.
CITY/ PROV/POSTAL CODE:
DESCRIPTION OF DAMAGE (please include tooth numbers):
PHONE NUMBER:
( )
PLEASE ATTACH A PREDETERMINATION OR ANY INCURRED CLAIMS.
X-RAYS ARE REQUIRED.
The cost, if any, of obtaining this information is at the expense of the patient/plan member.
Dental Accident Report Form EN (Rev 2013-04)) DEACC
click to sign
signature
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click to sign
signature
click to edit
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