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® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
VPS 108244
121760 & (02/2021)
SECTION 1 – GENERAL INFORMATION
By completing this form, you
are asking RBC Insurance
Company of Canada to change
the information you previously
provided.
Any previous beneciary
designation or trustee
appointment is revoked.
RBC Policy Number
If insured under an RBC
®
credit card, please indicate the type of the card
Insured Name
Last Name First Name Middle Initial
SECTION 2 – BENEFICIARY DESIGNATION
The beneciary designation
applies to Accidental Death
Benets under the policy. In the
event of a claim, the original of
this form will be requested.
If you are designating a
beneciary who is a minor, see
section 4.
For Residents of Quebec Only:
A spousal beneciary designation
is irrevocable unless you make
the designation revocable
by checking the box marked
“Revocable.”
Beneciary (You can name one beneciary or more) Date of Birth
YYYY/MM/DD
Relationship %
Last Name First Name Middle Initial
Last Name First Name Middle Initial
Last Name First Name Middle Initial
If you do not designate a beneciary, the proceeds will be paid to your estate.
For Residents of Quebec Only: I hereby make the above spousal beneciary designation:
Revocable; I may change this beneciary designation at any time.
SECTION 3 – DESIGNATING CONTINGENT BENEFICIARIES
If you wish to designate
contingent beneciaries, in the
event that there are no surviving
beneciaries at the time of your
death, please complete this
section.
If none of the beneciaries designated above are surviving at the time of my death, I declare that the following
contingent beneciaries shall receive the proceeds.
Contingent Beneciary Date of Birth
YYYY/MM/DD
Relationship %
Last Name First Name Middle Initial
Last Name First Name Middle Initial
Last Name First Name Middle Initial
If you do not designate a beneciary, the proceeds will be paid to your estate.
For Residents of Quebec Only: I hereby make the above spousal beneciary designation:
Revocable; I may change this beneciary designation at any time.
SECTION 4 – APPOINTMENT OF TRUSTEE
Recommended in all provinces, except Quebec, for any beneciary who is a minor or lacks legal capacity.
Trustee (Last Name, First Name) Relationship to Insured
Is hereby appointed Trustee to receive any payment due to any designated beneciary on record with RBC Insurance Company of Canada who is a minor
on the date such payment falls due.
SECTION 5 – AUTHORIZATIONS & DECLARATIONS
I reserve the right to change this designation. RBC Insurance Company of Canada assumes no responsibility for the validity or effect of this designation.
Signed at this day of
(City/Province) (Month/Year)
Witness (other than a beneciary) Signature of Insured
Please print 2 copies of this form. Return one signed copy to RBC Insurance 6880 Financial Drive, 5th Floor, Tower 1, Mississauga, ON L5N 7Y5.
Keep the other copy for your records.
Beneficiary
Designation
click to sign
signature
click to edit
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