Fillable Death Abroad Claimant Statement Death Abroad Claimant Statement (RBC Insurance)

Fill Online, Printable, Fillable, Blank Death Abroad Claimant Statement Death Abroad Claimant Statement (RBC Insurance) Form

Use Fill to complete blank online RBC INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Death Abroad Claimant Statement Death Abroad Claimant Statement (RBC Insurance)

On average this form takes 29 minutes to complete

The Death Abroad Claimant Statement Death Abroad Claimant Statement (RBC Insurance) form is 7 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 109 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your RBC Insurance forms online.

BROWSE RBC INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Death Abroad Claimant Statement
Death Abroad Claimant Statement Guidelines
To enable us to expedite this claim, please complete and return this document as soon as possible.
Print clearly and avoid the use of abbreviations where possible.
If there is insufficient space provided in any section of the form, continue on a separate piece of
paper.
With this statement please include:
• Attending Physician’s Statement
• Original Passport (or notarized copy of all pages)
• Original Plane Ticket or reasonable proof of travel
• Original Death Certificate from country of issue
• Original Burial or Cremation Certificate
• Physician’s/Medical Examiner’s Statement of Death
• Original Autopsy or Coroner’s Report
• Hospital records
• Police Accident Report
• Canadian Death Certificate (if remains were returned to Canada)
• Bills for hotel, medical treatment, cremation, burial or transportation of the body
Please return the completed questionnaire & documents to:
RBC Life Insurance Company
Attention: Claims Department
P.O Box 4435 Station A.
Toronto, Ontario M5W 5Y8
If you have any questions, you may call us at 1-877-519-9501.
RBC Life Insurance Company Claims October 14, 2009 PAGE 1 OF 6
® Registered trademarks of Royal Bank of Canada. Used under licence.
RBC Life Insurance Company Claims October 14, 2009 PAGE 2 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
COLLECTION AND USE OF PERSONAL INFORMATION
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
have your social insurance number, we may use it for tax related purposes and share it with the
appropriate government agencies.
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
®
.
Other uses of your personal information
• We ma
y 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” b
y
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 sit e at
www.rbc.com/privacy
RBC Life Insurance Company Claims October 14, 2009 PAGE 3 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
Death Abroad Claimant Statement
Part 1
Name of deceased
Last First Middle
Other names used
Last First Middle
Date of birth
Day Month Year
Place of birth
City Country
Passport number Date and place of issue
Please provide original passport or notarized copies of all
pages.
Name and address of last employer (or name of firm if self-employed)
Did the deceased use tobacco in any form?
Yes No If yes, date last used:___________________________
List the other companies with which the deceased had life insurance.
Company Name Effective Date of Insurance D/M/Y Amount of Insurance
List the physician(s) who attended to the deceased
in the last five years.
Physician’s name Address Date of visit (d/m/y) Reason for Visit
Date of departure from Canada Intended duration of visit
Day Month Year
Purpose of visit
Please provide original plane ticket or reasonable proof of travel.
Full name of travelling companion(s), if any
RBC Life Insurance Company Claims October 14, 2009 PAGE 4 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
13-Jan-2021
Part 2
Address abroad at time of death
Exact place of death
Date of death
Time of death A.M.
P.M.
Day Month Year
Cause of death
Please provide original death certificate from foreign country.
Part 3 – Please complete if cause of death was as a result of an accident
How did the accident occur?
Who witnessed the accident?
Give names and addresses.
Was anyone else injured? If so, give names and addresses.
Was a police investigation carried out? Yes
No If yes, please provide a copy of the final report.
Name of Police Officer and station involved
Name of hospital where deceased was taken
Name and address of Physician(s) who attended at time of death
Was there a post-mortem? Yes
No If yes, please provide a copy of the final report.
Was there a Coroner’s Inquest? Yes
No If yes, please provide a copy of the final report.
RBC Life Insurance Company Claims October 14, 2009 PAGE 5 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
Part 4 – Please complete if cause of death was as a result of an illness
Treatment Prescribed
Date of
onset of illness Symptoms:
___________________________
Day Month Year
Date of diagnosis
_______________________ ________________
_______________
Nature of illness
Name and address of Physician(s) who attended at time of death
Name and address of ho
spital if appropriate
Was there a post-mortem? Yes
No If yes, please provide a copy of the final report.
Part 5 – Burial/Cremation
Date of burial/cremation
Day Month Year
What documentation was obtained to enable the burial or cremation to take place?
Where did the burial or cremation take place?
Names and addresses of two people (not related to the deceased) who were present at the burial or cremation.
1.
2.
If place of burial or cremation is different from place of death, please provide original travel documents and explanation
as to why.
RBC Life Insurance Company Claims October 14, 2009 PAGE 6 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
_________________________________________
_________________________________________
_________________________________________
Declarations and Signatures
To be completed by the estate and/or named beneficiary of the deceased.
Last Name
First Name
Address
Telephone Number
Social Insurance Number
You are claiming as
(check one box only)
beneficiary
estate’s executor
assignee
other
____________
(please specify)
( ) Are you 18 or over? yes no
If no, your date of birth
(dd-mm-yyyy)
I declare the questions answered on this statement are complete and true to the best of my knowledge.
I authorize any health care professional, health or social service establishment, insurance company, the
Medical Information Bureau holding personal information concerning the deceased, particularly medical
information, to supply this information to RBC Life Insurance Company and its reinsurers. Such information
will be provided for investigations necessary to adjudicate this claim or assess the validity of the policy as
issued.
I understand that if I refuse to provide this authorization, RBC Life Insurance Company will be unable to
adjudicate this claim or assess the validity of the policy as issued.
A photocopy of the signed authorization to obtain this information will be as legally valid as the original.
This authorization will be valid until revoked by written notice to RBC Life Insurance Company.
Date
_____________________________________
Day Month Year
Signature
Relationship to deceased
Signature of Witness
__________________________________
Name (please print)
____________________________________
Name of Witness (please print)
RBC Life Insurance Company Claims October 14, 2009 PAGE 7 OF 7
® Registered trademarks of Royal Bank of Canada. Used under licence.
RESET
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Death Abroad Claimant Statement Death Abroad Claimant Statement (RBC Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document