MASS_NRG_A_Bleed_Mask_Op1
Life Insurance Application
Use this application for RBC
Your
Term™ Life Insurance
and available benets and riders
VPS 105596 89604 (10/2019)
Page 1 of 28
TABLE OF CONTENTS
For Your Client
§ Collection and Use of Personal Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
§ Consumer Fact Sheet Pre-Notice ....................................................................3
Part 1
§ Personal and Employment Information ................................................................4
§ Main Purpose of Insurance .........................................................................5
§ Coverage Applied for ..............................................................................5
§ Existing and Pending Coverages .....................................................................6
§ Beneciary ......................................................................................6
§ Ownership ......................................................................................7
§ Appointment of Trustee ............................................................................7
§ Financial Information ..............................................................................8
§ Additional Information ........................................................................... 8-9
Part 2
§ Medical Information ........................................................................... 10-16
Part 3
§ Premium and Payment Information ..................................................................18
§ Pre-Authorized Debit (PAD) Agreement ...............................................................18
§ Application for Children’s Term Rider .............................................................. 19-20
§ Agreement .....................................................................................22
§ Authorization ...................................................................................24
§ Temporary Life Insurance Application ............................................................. 26-27
§ Representative’s Report ..........................................................................28
TABLE OF CONTENTS
VPS 105596 89604 (10/2019)
Page 2 of 28
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 conrm 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, nancial 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 benet, 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 condentiality of this information.
In the event our service provider is located outside 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 nancial 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 rm other than RBC Insurance
®
.
Other uses of your personal information
We may 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, afliated corporations. RBC companies include our afliates which are
engaged in the business of providing any one or more of the following services to the public: deposits, loans and other personal nancial
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” by 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.”
DETACH AND GIVE TO PROPOSED INSURED
COLLECTION AND USE OF PERSONAL INFORMATION
VPS 105596 89604 (10/2019)
Page 3 of 28
COLLECTION AND USE OF 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 “Financial fraud prevention and privacy protection”
brochure, by calling us at the toll free number shown above or by visiting our website at www.rbc.com/privacysecurity.
CONSUMER FACT SHEET PRE-NOTICE
Information regarding your insurability and claims will be treated as condential. RBC Life Insurance Company (RBC Life) or its
reinsurer(s) may, however, make a brief report thereon to the MIB, Inc., a non-prot membership organization of life insurance companies,
which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health
insurance coverage, or a claim for benets is submitted to such a company, MIB, upon request, will supply such company with the
information in its le. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your le. If you
question the accuracy of the information in MIB’s le, you may contact MIB and seek a correction.
The address of MIB’s information ofce is
MIB, Inc.,
330 University Avenue,
Toronto, Ontario,
Canada, M5G 1R7
Telephone: 416-597-0590
Website: www.mib.com
RBC Life or its reinsurer(s) may also release information in its le to other life insurance companies to whom you may apply for life or
health insurance, or to whom you submit a claim for benets.
PERSONAL HISTORY INTERVIEW (PHI)
As part of the underwriting process, you may be asked to respond to a telephone interview. The Personal History Interview (PHI) is
conducted by specially trained interviewers. The interview will take approximately 20 minutes. Since we want to conduct the interview at
a time most convenient for you, we ask you on the application whether you wish to be contacted at home or at work and the best time to
call.
The questions asked by the interviewer amplify the information on your application for insurance. These questions relate to personal,
nancial and medical aspects of insurability and will form part of the contract. The answers contained in the Personal History Interview
and/or supplementary questionnaire(s) completed by you during a telephone interview and included in your contract are true and correct
and form part of your application for insurance. We also use the PHI process to gather information which may have been omitted or only
partially explained. Because of the nature of the information obtained, the PHI will only be conducted directly with you.
Any information obtained during the PHI will be kept strictly condential and will not be released to anyone without your written consent.
Your co-operation in this process is greatly appreciated and enables us to provide you with the best quality underwriting.
DETACH AND GIVE TO PROPOSED INSURED
CONSUMER FACT SHEETPERSONAL HISTORY INTERVIEW (PHI) COLLECTION AND USE OF PERSONAL INFORMATION
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PART 1: PERSONAL AND EMPLOYMENT INFORMATION
(You/Your refers to the Proposed Insured)
PROPOSED INSURED A
(Check one)
Mr. Mrs. Ms. Miss Dr. Other
1. Print name as legally known:
a. Last
b. First & Middle
c. Former Name
d. Birthdate: Day Month Year
e. Birthplace: Country
f. Sex: M F
g. Smoker Non-Smoker
h. Do You understand English or French? Yes No
PROPOSED INSURED B
(Check one)
Mr. Mrs. Ms. Miss Dr. Other
4. Print name as legally known:
a. Last
b. First & Middle
c. Former Name
d. Birthdate: Day Month Year
e. Birthplace: Country
f. Sex: M F
g. Smoker Non-Smoker
h. Do You understand English or French? Yes No
If No, please ensure a Statement of Understanding is signed by the
Proposed Insured and the Proposed Owner(s) and submitted with this Application.
i. Is a French language Policy requested? Yes
No
j. Canadian Citizen Permanent Resident
Other (Specify)
k. How long have you resided in Canada?
yrs
mths
i. Canadian Citizen
Permanent Resident
Other (Specify)
j. How long have you resided in Canada?
yrs
mths
5. Home Address: Same as Proposed Insured A
2. Home Address: a. Number
b. Street
c. City
d. Province e. Postal Code
f. Email Address
g. Home Phone No.
( )
Work Phone No.
( )
Mobile Phone No.
( )
OR a. Number
b. Street
c. City
d. Province e. Postal Code
f. Email Address
g. Home Phone No.
( )
Work Phone No.
( )
Mobile Phone No.
( )
3. a. Business/Employer Name
b. Business/Employer Address: Suite No.
c. Street
d. Province e. Postal Code
f. City
g. Phone No.
( )
h. Occupation
i. Describe nature of business
j. Describe duties
k. How long with this employer?
6. a. Business/Employer Name
b. Business/Employer Address: Suite No.
c. Street
d. Province e. Postal Code
f. City
g. Phone No.
( )
h. Occupation
i. Describe nature of business
j. Describe duties
k. How long with this employer?
RBC Life Insurance Company, PO Box 212, Station A, Mississauga, ON L5A 9Z9
1-800-461-1413 www.rbcinsurance.com
APPLICATION FOR LIFE INSURANCE
TO RBC LIFE INSURANCE COMPANY
PERSONAL AND EMPLOYMENT INFORMATION
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MAIN PURPOSE OF INSURANCE
7. a. Personal
Income Replacement
Estate Conservation
Other
Please explain
b. Business
Protect key personnel
Fund buy-sell agreement
Other
Please explain
COVERAGE APPLIED FOR
Joint plans with more than 2 lives to be insured are available by special quote only. If more than 2 joint lives, please submit a separate
Application form for each Proposed Insured not covered by this Application and cross reference them to each other.
8. Amount of Life Insurance Coverage on the Base Plan
$
9. Insurance Plan and Coverage Option for the Base Plan:
Term Length Single Life JFTD
RBC YourTerm
®
(10 to 40)
10.
Name(s) of Person(s) To Be Insured Under the Base Plan
Total Disability Waiver Accidental Death Benet
a.
Yes
No
$
b.
Yes
No
$
c.
Yes
No
$
d.
Yes
No
$
e.
Yes
No
$
11. Term Rider 1:
Term Length Single Life JFTD Face Amount $
RBC YourTerm
®
(10 to 40)
Name(s) of Person(s) To Be Insured Under This Term Rider Coverage Application No.
a.
b.
c.
d.
Term Rider 2:
Term Length Single Life JFTD Face Amount $
RBC YourTerm
®
(10 to 40)
Name(s) of Person(s) To Be Insured Under This Term Rider Coverage Application No.
a.
b.
c.
d.
12. Payor Waiver:
Name of Payor
Application No.
Relationship to Proposed Owner(s)
13. Children’s Term Rider Please complete the Application for Children’s Term Rider on pages 19 and 20.
Face Amount for Each Insured Child
$
MAIN PURPOSE
COVERAGE APPLIED FOR
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EXISTING AND PENDING COVERAGES
Proposed
Insured
14. a. Do You have any Life coverages in force or pending, including any with RBC Life? ................. A: Yes No
B: Yes No
If Yes, provide details below. Complete Replacement forms where necessary.
Proposed
Insured
A B
Name of Insurance
Company
Amount of Life Insurance
(including term riders)
Year and
Month
Issued
Is the insurance applied for intended to
replace any insurance now in force with
any company?
$
Personal
Business
Yes
No
Policy #
$
Personal
Business
Yes
No
Policy #
$
Personal
Business
Yes
No
Policy #
$
Personal
Business
Yes
No
Policy #
Proposed
Insured
Proposed
Insured
A B
Amount
Applied for
Coverage Type Name of Insurer
b. Have You applied for life, critical illness
or disability insurance concurrently with
this Application or within the past
12 months with any other company?
A: Yes
No
B: Yes No
$
Life CI DI
$
Life CI DI
If Yes, indicate details
$
Life CI DI
BENEFICIARY
All beneciaries are revocable unless otherwise stated, except in Quebec where the designation of a legally married spouse of the owner
is irrevocable, unless expressly stated to be revocable. An irrevocable beneciary cannot be changed without the written consent of the
designated irrevocable beneciary. In all provinces, except Quebec, if the beneciary is a minor, a trustee should be named in order to
avoid a payment into court. Complete the Appointment of Trustee section on page 7. In Quebec, benets payable to minors are payable to
the surviving parent(s) as tutor(s).
If naming a minor as an irrevocable beneciary, you should be aware that the consent of an irrevocable beneciary is required for any
change which impacts the value of the Policy, and a minor cannot give that consent.
If all beneciaries predecease the Proposed Insured, the proceeds are payable to the contingent beneciary if any, otherwise to the Owner
or the Owner’s Estate.
Ensure total shares of both the Primary and Contingent beneciaries equal 100% respectively.
15.
Proposed
Insured
A B
Full Name of Beneciary
(First) (Middle) (Last)
Revocable
or
Irrevocable
Relationship to Proposed
Insured (Proposed Owner
in Quebec)
Primary or
Contingent
%
Share
EXISTING AND PENDING COVERAGES
BENEFICIARY
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PROPOSED OWNER(S)
16. a. Proposed Insured A
Proposed Insured B
Proposed Insureds A and B Jointly*
If selected, what is the relationship between Proposed Insureds A and B?
Other
(Please complete the section below)
b.
(Check one) Mr. Mrs. Ms. Miss Dr. c. First or Company Name
d. Middle Name
e. Last Name
f. Relationship to Proposed Insureds A and B
g. Mailing Address (for billing and correspondence) Street
h City
i. Province
j. Postal Code
k. Attention
l. E-mail Address
* If jointly owned, ownership is to be with right of survivorship unless otherwise indicated. (In Quebec, please name one another as
Contingent Owners if right of survivorship is desired.)
JOINT PROPOSED OWNER (If different than joint ownership by Proposed Insureds A and B)
17. a.
(Check one) Mr. Mrs. Ms. Miss Dr. b. First or Company Name
c. Middle Name
d. Last Name
e. Relationship to Proposed Insureds A and B
f. Mailing Address (for billing and correspondence) Street
g. City
h. Province
i. Postal Code
j. Attention
E-mail Address
k. Relationship to Other Joint Owner
Joint ownership is to be with right to survivorship unless otherwise indicated. (In Quebec, please name one another as Contingent
Owners if right to survivorship is desired.)
CONTINGENT OWNER
Must be completed if purchasing Children’s Term Rider.
If all Owners predecease the Proposed Insured, in the absence of a Contingent Owner, ownership passes to the estate of the last
surviving Owner.
18. a.
(Check one) Mr. Mrs. Ms. Miss Dr. b. First or Company Name
c. Middle Name
d. Last Name
e. Relationship to Proposed Insureds A and B
APPOINTMENT OF TRUSTEE
Complete if the Proposed Owner wishes to name a trustee for a beneciary and such a trustee has not already been appointed
under a written Trust Agreement.
This appointment applies to benets payable to any beneciary designated under the Policy who, at the time benets are payable, is a
minor or lacks legal capacity to give a valid discharge. Payment of benets to the trustee discharges RBC Life Insurance Company to the
extent of the payment.
I authorize the trustee in his/her or its sole discretion to use the benets for the education or maintenance of the beneciary and to
exercise any right of the beneciary under the Policy.
The trust for any beneciary will terminate once that beneciary both is of the age of majority and has legal capacity to give a valid
discharge, and I direct the trustee at that time to deliver to the beneciary any assets held in trust for that beneciary. I or my personal
representative (in Quebec: my tutor, curator, liquidator or mandatory in the event of incapacity) may in writing appoint a new trustee to
replace a former trustee.
I appoint
First Name Middle Name Last Name
as trustee to receive, in trust, benets under the Policy.
Relationship to Proposed Insured
OWNERSHIPAPPOINTMENT OF TRUSTEE
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FINANCIAL INFORMATION
19.
Proposed
Insured A
Proposed
Insured B
a. What is Your annual earned income from employment in Canadian dollars? ..........
$ $
b. What is Your estimated net worth in Canadian dollars? .........................
$ $
c. Amount of mortgage outstanding on personal residence and/or cottage? ...........
$ $
d. If not self supporting, what is the annual gross amount of the family earned income? ..
$ $
e. What is Your annual income in Canadian dollars from other sources? ..............
$ $
Describe
“other sources”
of income
A B
Proposed
Insured
f. Have You within the past 5 years declared personal or corporate bankruptcy? ...................A: Yes No
B: Yes No
If Yes, provide the discharge date and complete details below.
A B Discharge Date Complete Details
A
B
20. If applying for business insurance, complete the following:
Proposed
Insured A
Proposed
Insured B
a. Book Value of Business in Canadian Dollars ..................................
$ $
b. Fair Market Value of Business in Canadian Dollars .............................
$ $
c. Before Tax Net Annual Income of Business in Canadian Dollars ...................
$ $
d. Please complete the following:
Name of Principals
% of Business
Owned
Amount of Life Insurance
in Force or Pending
Insurance Company
ADDITIONAL INFORMATION
Proposed
Insured
21. a. Have You collected EI (Employment Insurance), disability benets, workers’
compensation benets, CPP or QPP disability benets, income replacement benets,
or any form of social assistance in the past 12 months? . ...................................A: Yes No
B: Yes No
If Yes, provide details.
A B Date Started Date Ended EI Disability WCB Other
Describe
Describe
Describe
Proposed
b. Have You within the past 24 months been a student pilot, or piloted a plane, ultra-light Insured
or glider, or do You have any intention of doing so in the future? . .............................A: Yes No
B: Yes No
If Yes, please complete the Aviation Questionnaire.
FINANCIAL INFORMATION ADDITIONAL INFORMATION
VPS 105596 89604 (10/2019)
Page 9 of 28
Proposed
c. Have You within the past 12 months traveled outside Canada or the United States of Insured
America, or do You intend to do so within the next 12 months? . ..............................A: Yes No
B: Yes No
If Yes, provide details.
A B Dates Countries/Cities Length of Stay Reason
Proposed
d. Have You within the past 24 months engaged in any hazardous or contact sports or Insured
activities, including but not limited to racing, scuba diving deeper than 100ft (30m),
skydiving, heli-skiing or back-country skiing, or do You intend to do so? . .......................A: Yes No
B: Yes No
If Yes, provide details.
A B Hazardous Sport or Activity Type Dates, Frequency, Professional/Amateur, Recreational/Commercial
Proposed
e. Have You ever had life, disability or critical illness insurance rated, modied, rejected, Insured
rescinded, or have You been denied renewal or reinstatement? . .............................A: Yes No
B: Yes No
If Yes, provide details.
A B
Indicate Type
of Insurance
Rated
Modi-
ed
Re-
jected
Re-
scinded
Denied Renewal or
Reinstatement
Insurance Company Reason
Proposed
f. Have You within the past 10 years been convicted of any criminal offence, or are there Insured
any such charges pending? ..........................................................A: Yes No
B: Yes No
If Yes, provide details.
A B Date of Incident Details Including Outcome
A
B
Proposed
g. Have You within the past 10 years been convicted of any driving offences or violations, Insured
including impaired driving, and/or have You had a driver’s license revoked or suspended,
or are any such charges pending?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A: Yes No
B: Yes No
If Yes, provide the driver’s license number and complete details below, including dates, offence type, how many
km/h over the limit.
A B Driver’s License Number Details, Dates, Offence Type(s), km/h Over Limit
ADDITIONAL INFORMATION
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PART 2: MEDICAL HISTORY: PROPOSED INSURED A (You/Your refers to the Proposed Insured)
When answering the questions on this form, DO NOT provide information about any genetic test you have taken or plan to take. A genetic
test is a type of medical test which analyzes DNA, RNA, or chromosomes. DO provide information about other types of medical tests.
Legal Name of Proposed Insured
1. Paramedical requested? ...................................................................... Yes No
!
If Yes, completing pages 10 and 12-16 for Proposed Insured A is not required.
2. Current Height
cm ft/in Current Weight kg lb
3. Have You lost 10lb/5kg or more within the past 12 months? Yes No
If Yes
Reason Amount Lost
kg lb
4. Are You presently under medical observation or investigation, treatment, therapy,
counselling, or taking medication? ............................................................. Yes
No
Details
Name of Medication Dose Amount Frequency Taken Date Started
5. Have You had any symptoms or complaints regarding Your health for which You have not yet
consulted a physician or received treatment? ..................................................... Yes
No
Details
6. Who is Your family physician or regular healthcare provider or clinic?
(If none, write “None.”)
Provide the full address and phone number.
7. Provide the name of the healthcare provider who has Your most recent health record if different from Your regular healthcare
provider or clinic.
8. What are the date and reason for Your last consultation with ANY physician or healthcare provider, the name of the provider, and the
outcome/results?
9. Was any follow-up, further investigation or referral to another healthcare professional recommended? ......... Yes No
Details
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
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PART 2: MEDICAL HISTORY: PROPOSED INSURED B (You/Your refers to the Proposed Insured)
When answering the questions on this form, DO NOT provide information about any genetic test you have taken or plan to take. A genetic
test is a type of medical test which analyzes DNA, RNA, or chromosomes. DO provide information about other types of medical tests.
Legal Name of Proposed Insured
10. Paramedical requested? ...................................................................... Yes No
!
If Yes, completing pages 11-16 for Proposed Insured B is not required.
11. Current Height
cm ft/in Current Weight kg lb
12. Have You lost 10lb/5kg or more within the past 12 months? Yes No
If Yes
Reason Amount Lost
kg lb
13. Are You presently under medical observation or investigation, treatment, therapy,
counselling, or taking medication? ............................................................. Yes
No
Details
Name of Medication Dose Amount Frequency Taken Date Started
14. Have You had any symptoms or complaints regarding Your health for which You have not yet
consulted a physician or received treatment? ..................................................... Yes
No
Details
15. Who is Your family physician or regular healthcare provider or clinic?
(If none, write “None.”)
Provide the full address and phone number.
16. Provide the name of the healthcare provider who has Your most recent health record if different from Your regular healthcare
provider or clinic.
17. What are the date and reason for Your last consultation with ANY physician or healthcare provider, the name of the provider, and the
outcome/results?
18. Was any follow-up, further investigation or referral to another healthcare professional recommended? ......... Yes No
Details
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
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Page 12 of 28
MEDICAL DETAILS PROPOSED INSUREDS A AND B
19. In the past 24 months have you used cigarettes, e-cigarettes, vaping products, cigars, water pipes,
betel nut, smoking cessation products or nicotine or tobacco in any form? ............................A: Yes No
B: Yes No
A B
Product Type
(“vaping”, cigarettes, etc.)
Quantity and
Frequency of Use
Date Last Used
Details of Smoking Cessation Therapy
(type, when started/completed)
A
B
20. Have You used marijuana and/or hashish within the past 5 years? ................................A: Yes No
B: Yes No
If Yes, indicate the type, quantity and frequency of use, and date last used.
A:
B:
21. Do You consume alcoholic beverages? .......................................................A: Yes
No
B: Yes No
If Yes, provide details.
Proposed Insured A:
Amount Day Week Month Year
Beer cans/bottles
Wine glasses
Liquor ml/oz
Proposed Insured B:
Amount Day Week Month Year
Beer cans/bottles
Wine glasses
Liquor ml/oz
22. Have You ever sought or received advice or treatment relating to alcohol use, or used alcohol excessively? ...A: Yes No
B: Yes No
If Yes, please complete Alcohol Questionnaire.
23. Have You ever used cocaine, barbiturates, crack, or any other narcotic drug, or ever sought or
received advice or treatment for the use of drugs, prescribed or non-prescribed? ......................A: Yes No
B: Yes No
If Yes, indicate the type of drug, quantity and frequency of use, and date last used.
A:
B:
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
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Page 13 of 28
Have You ever had any known indication of or been treated for:
24. a. Acquired immune deciency syndrome, AIDS related complex, AIDS related conditions; or have
You tested positive for antibodies to the AIDS virus or HIV? ....................................A: Yes
No
B: Yes No
Details
A:
B:
b. Any disease or disorder of the eyes, ears, nose or throat (including loss of speech)? .................A: Yes
No
B: Yes No
Details
A:
B:
c. Sleep apnea, chronic insomnia, or any other sleep disorder? ...................................A: Yes
No
B: Yes No
Details
A:
B:
d. Chest pain, heart attack, angina, abnormal ECG, irregular pulse, heart murmur, high blood pressure, high
cholesterol, peripheral vascular disease or any disease or disorder of the heart or circulatory system? ...A: Yes
No
B: Yes No
Details
A:
B:
e. Stroke, transient ischemic attack (TIA), headaches, cognitive impairment, memory disorder,
Parkinson’s disease, Alzheimer’s disease, motor neuron disease, Huntington’s disease, fainting spells,
dizziness, seizures, epilepsy, paralysis, multiple sclerosis, muscle weakness, numbness or
tingling of the limbs, or any disease or disorder of the brain or nervous system? ....................A: Yes
No
B: Yes No
Details
A:
B:
f. Any disease or disorder of the kidneys, urinary tract, bladder, prostate, or genital organs,
or kidney stones, or albumin, blood, or sugar in the urine? .....................................A: Yes
No
B: Yes No
Details
A:
B:
g. Anxiety, depression, nervousness, stress, fatigue, burnout, eating disorder, other emotional disorder,
psychiatric disorder, mental disorder or psychosis; or have You ever attempted suicide?. .............A: Yes
No
B: Yes No
Details
A:
B:
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
VPS 105596 89604 (10/2019)
Page 14 of 28
Have You ever had any known indication of or been treated for:
h. Chronic fatigue, chronic fatigue syndrome, Epstein-Barr virus, bromyalgia, or chronic pain?. ..........A: Yes No
B: Yes No
Details
A:
B:
i. Cancer, dysplastic nevi, tumour, cyst, mass, lesion, lump, nodule, polyp or other growth, any
disorder of the skin or lymph glands, blood disorder or any form of malignant disease?. ..............A: Yes
No
B: Yes No
Details
A:
B:
j. Diabetes, endocrine disorder, elevated blood sugar, thyroid disease, rheumatism,
rheumatic fever, lupus, gout, or syphilis? ...................................................A: Yes
No
B: Yes No
Details
A:
B:
k. Any disease or disorder of the reproductive organs or breast including lumps, cysts or other
masses, other physical changes, abnormal mammogram ndings or any biopsy? ...................A: Yes
No
B: Yes No
Details
A:
B:
l. Any amputation or deformity, hernia or rupture, deep vein thrombosis or varicose veins? .............A: Yes
No
B: Yes No
Details
A:
B:
m. Any arthritis, disease or disorder of the muscles, bones, hip, ankle, knee, wrist, elbow, shoulder,
hands, feet or any other joint?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A: Yes
No
B: Yes No
Details
A:
B:
n. Any type of back or spinal trouble including sprain, strain, or disc disease or disorder? ...............A: Yes
No
B: Yes No
Details
A:
B:
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
VPS 105596 89604 (10/2019)
Page 15 of 28
Have You ever had any known indication of or been treated for:
o. Any type of shortness of breath, persistent cough, asthma, emphysema, bronchitis, pleurisy,
tuberculosis, or any disease or disorder of the chest or lungs? ..................................A: Yes No
B: Yes No
Details
A:
B:
p. Any type of peptic ulcer, indigestion, colitis, or any disease or disorder of the stomach,
colon or intestines, gall bladder, liver, pancreas; or have You tested positive for hepatitis
and/or been told You are a carrier? ........................................................A: Yes
No
B: Yes No
Details
A:
B:
Other than the information provided in Part 2, numbers 1-24, have You in the past 10 years:
25. a. Been examined by or consulted a physician, chiropractor, psychologist, physiotherapist,
osteopath, homeopath, or other practitioner? . ...............................................A: Yes
No
B: Yes No
Details
A:
B:
b. Been under observation or treatment in any hospital or other institution or facility,
or been advised to be admitted? ..........................................................A: Yes
No
B: Yes No
Details
A:
B:
c. Had an X-ray, ECG, CT scan, MRI, blood or urine test, abnormal PSA (Prostate Specic Antigen)
test, or other diagnostic tests? ...........................................................A: Yes
No
B: Yes No
Details
A:
B:
d. Been advised to have any diagnostic test, be hospitalized, or have surgery which was not completed? ..A: Yes
No
B: Yes No
Details
A:
B:
!
Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider,
and date of recovery.
MEDICAL INFORMATION
VPS 105596 89604 (10/2019)
Page 16 of 28
26. Have Your natural parents, brothers or sisters, either living or dead, ever suffered from any of the following
conditions: heart disease, polycystic kidney disease, high blood pressure, a stroke, diabetes, cancer, multiple
sclerosis, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, motor neuron disease
or any form of hereditary disease? ...........................................................A: Yes No
B: Yes No
If Yes, complete the chart below.
A B Condition Mother
Age at
Onset
Father
Age at
Onset
Sister
Age at
Onset
Brother
Age at
Onset
Female Applicants Only
27. a. Have You ever had a miscarriage or other complication of pregnancy? ...........................A: Yes
No
B: Yes No
Details
A:
B:
b. Are You pregnant? ....................................................................A: Yes
No
B: Yes No
If Yes, give due date.
A:
B:
As needed, provide additional details below to any Yes answers from Part 2.
Question
Number
Conditions, Symptoms, Duration, Results and Treatment
Date of
Onset
Name of Healthcare Provider
Date of
Recovery
MEDICAL INFORMATION
VPS 105596 89604 (10/2019)
Page 17 of 28
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PART 3: PREMIUM AND PAYMENT INFORMATION
1. a. Method of Payment: Monthly Annually
b. Pre-Authorized Debit Plan (PAD) (Complete the PAD Agreement below) OR Direct Bill
c. Initial deposit collected? Yes No (Payment On Delivery)
If initial deposit is collected, it is in exchange for the Receipt and TIA (page 26).
d. Temporary Life Insurance Agreement (TIA) premium to be withdrawn by PAD? Yes
No
e. TIA premium collected for life insurance? Yes No If Yes please indicate amount collected:
$
f. If TIA has not been applied for, is the initial life insurance premium to be withdrawn by PAD? Yes No
2. PRE-AUTHORIZED DEBIT (PAD) AGREEMENT
Ensure You read and understand the section entitled “Collection and Use of Personal Information.”
The Payor(s) named below agrees that:
a. RBC Life Insurance Company (RBC Life) is authorized to make scheduled monthly withdrawals against the account at the nancial
institution below or any other nancial institution that the Payor(s) may later designate to pay the premium in accordance with the
premium schedule set out in this Policy/these Policies, including the initial premium and/or the Temporary Insurance Agreement
premium, if requested in this Application.
b. RBC Life is not required to provide notication before the Temporary Insurance Agreement premium and/or the initial
premium is debited, or if the amount of the withdrawal should vary.
c. Unless otherwise indicated in the Special Requests section below, such withdrawals shall be dated on the day of the month on which
the premium is due under the Policy or, if more than one Policy is included in this Agreement, the withdrawals shall be dated to
coincide with the existing Policy/Policies.
d. The nancial institution indicated below is authorized now or at any subsequent time to honour any requests made by RBC Life to
withdraw premiums or fees from the account indicated below, which may include a redraw within 30 days should any withdrawal not
clear the account.
e. Notication of any change to the information provided below shall be given to RBC Life by the Payor(s) a minimum of 5 days prior
to the next scheduled withdrawal. The Payor(s) agrees that from time to time they may authorize RBC Life to deduct such payments
from another account upon the Payor’s oral or written instructions.
f. This Agreement will terminate in respect of all Policies included in it upon 10 days written notice by RBC Life or by the Payor(s).
The Payor(s) may obtain further information on their right to cancel a PAD agreement by visiting the Payments Canada website at
www.payments.ca.
g. In the event that a PAD is disputed, the Payor(s) agrees to contact RBC Life. For recourse purposes, this PAD is considered a
Personal PAD.
The Payor(s) has certain recourse rights if any debits do not comply with this Agreement. For example, the Payor(s) has the right to
receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain more information
on recourse rights, the Payor(s) may contact their nancial institution or visit www.payments.ca.
h. The names and signatures of all persons required to authorize withdrawals from the account indicated are included below.
i. Add to existing PAD with policy number(s)
j. Special Requests (Withdrawals must be between the 1
st
– 28
th
of the month)
Bank Information: Please attach a specimen cheque marked “Void” (a line of credit account cannot be used).
Name of Bank or Financial Institution Transit Number Bank Number Account Number
Address
City Province
Postal Code
Dated at this day of
City/Province Month/Year
Print Legal Name of Payor (Account Holder) Print Legal Name of Second Payor (Account Holder) (if any)
Signature of Payor Signature of Second Payor (if any)
!
PREMIUM AND PAYMENT INFORMATION
VPS 105596 89604 (10/2019)
Page 19 of 28
APPLICATION FOR CHILDREN’S TERM RIDER
Must be the natural or adopted child of a Life Insured named in the Life Insurance Application.
A Contingent Owner must be named in the main Application (see question 18, page 7).
All children must be between 14 days and 20 years of age.
Any child age 16 or over, or age 18 or over in Quebec, must sign the Application.
The beneciary of this benet will be the Proposed Insured or Proposed Joint Insureds under the Policy.
Children’s Names
a. First Name
Middle Name
Last Name
Female Male
Date of Birth (dd/mm/yy)
Height
cm
ft/in Weight kg
lb
Relationship to Proposed Insured(s)
Relationship to Proposed Owner(s)
b. First Name
Middle Name
Last Name
Female Male
Date of Birth (dd/mm/yy)
Height
cm
ft/in Weight kg
lb
Relationship to Proposed Insured(s)
Relationship to Proposed Owner(s)
c. First Name
Middle Name
Last Name
Female Male
Date of Birth (dd/mm/yy)
Height
cm
ft/in Weight kg
lb
Relationship to Proposed Insured(s)
Relationship to Proposed Owner(s)
Children’s Medical History YES NO
1. Has any insurance application for any child been declined, postponed, or modied in any way? .......................
2. Do any of the children have any physical or mental impairment, or have they had any illness, impairment
or injury that has required treatment or an operation? ........................................................
3. Are any of the children currently on medication, or has any treatment or diagnostic test been advised
that has not been completed? ..........................................................................
4. Do all of the above children reside with the Proposed Insured? ................................................
If No, provide details below about who the child lives with and how often the Proposed Insured sees the child.
5. What was the reason, the date of, and the result of the child’s last visit to a healthcare professional? Please answer below and include
the healthcare professional’s name, professional designation, address, postal code and phone number.
Child Question # Details
!
APPLICATION FOR CHILDREN’S TERM RIDER
VPS 105596 89604 (10/2019)
Page 20 of 28
Children’s Term Rider Agreement and Authorization
I certify that to the best of my knowledge the answers given are full, complete and true, and agree that they shall form part of my Life
Insurance Application to RBC Life Insurance Company.
I understand and authorize the Company (RBC Life Insurance Company and its reinsurers) to conduct such investigation as is necessary
and to gather personal information concerning me and/or my child (as named on this Application for Children’s Term Rider included in the
Life Insurance Application). I understand that the Company will create and maintain les that contain personal information concerning me
and/or my child. I also understand that access to personal information concerning me and/or my child will be limited to the employees of,
and other persons engaged by, the Company in performance of their duties, or the persons to whom I have granted access, in writing, or
to any other person authorized by law.
I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me and/
or my child, I will be permitted to review copies of documents containing said personal information in the possession of the Company, upon
paying reasonable copying charges. I further understand that I will be permitted to request access to such documentation and to have any
errors in the personal information noted and corrected by formulating a written request to the Company.
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information,
records or other data regarding me and/or my child, my and/or my child’s medical history or treatment, or my and/or my child’s past and
present income or employment that is relevant to this Application that they have in their possession or control.
Persons to whom this Authorization applies: Any licensed physician, nurse, counselor, psychologist, social worker, therapist, pharmacist,
physiotherapist, chiropractor, or other rehabilitation professional or other healthcare practitioner; and also any hospital, clinic, pharmacy,
or other medical facility or provider of healthcare or treatment; and also the provincial health insurance plan, any insurance or reinsurance
company or other nancial institution; and also my and/or my child’s employer or former employers; and also any federal or provincial
government department or organization, including the federal or provincial income tax authorities and provincial motor vehicle divisions;
and also the MIB, Inc.; and also any other person, agency, credit bureau or institution having information, records or data regarding me
and/or my child. This Authorization to obtain information is valid until revoked by me in writing. If I choose to revoke this Authorization to
obtain information, consequences may include termination of the underwriting process and/or the Policy, if one has been issued.
I understand that any information, records or data received by the Company pursuant to this Authorization, both medical and non-medical,
will be used for the assessment of insurance risk for underwriting purposes, for the purpose of evaluating any claim for benets, assessing
the validity of the Policy as issued, and issuing and delivering the Policy. Only to the extent reasonably necessary for those purposes, I
authorize the Company to disclose any of the said information, records or data received: to the MIB, Inc.; to other insurance companies or
any reinsurer; and to my Servicing Representative, such as my insurance advisor or broker. This Authorization to disclose information as
reasonably necessary is valid until revoked by me in writing.
I authorize the Company to disclose to my Servicing Representative material information regarding my and/or my child’s health and
personal history solely for the purpose of explaining underwriting decisions. This disclosure could include history of mental illness,
infectious disease, drug and alcohol use, record of criminal activity, or other facts that have a material effect on the Company’s decision
to insure me and/or my child. This Authorization to disclose information for this purpose is valid until 60 days after the later of the day
the Company issues a new or amends the existing Policy; or the day the Company noties me in writing that my Application has been
declined, withdrawn, or led incomplete.
I do not agree to the disclosure of health and personal information to the Servicing Representative
I also authorize the Company to release to my and/or my child’s healthcare professional any medical information obtained for this
insurance Application, including the results of any blood or urine test or urine drug screening tests for the purpose of revealing ndings that
might require further investigation or treatment or for the purpose of explaining any underwriting decision. This Authorization to disclose
medical information is valid until revoked by me in writing. A photocopy of this Authorization, as executed by me, will be as valid as the
original. Any alteration of this Authorization will render it null and void.
Signature of Parent/Guardian (tutors in Quebec)* Signature of Parent/Guardian (tutors in Quebec)*
Signature of Any Child Age 16 or Over (age 18 or over in Quebec) Signature of Any Child Age 16 or Over (age 18 or over in Quebec)
* In Quebec, if there is more than one tutor, all tutors must sign unless the one tutor has given the other a specic mandate to act
unilaterally on the child’s behalf.
APPLICATION FOR CHILDREN’S TERM RIDER
VPS 105596 89604 (10/2019)
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VPS 105596 89604 (10/2019)
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AGREEMENT
The Proposed Owner and the Proposed Insured, if other than the Proposed Owner, declare to the best of my/our
knowledge that all statements and answers in all parts of this Application and in any supplement to this Application are full,
complete and true, and agree that:
1. RBC Life Insurance Company (RBC Life) has 90 days to consider and act upon this Application from the date this
Application was signed. If RBC Life has not given notice of approval or rejection within that time, this Application shall
be considered to be declined.
2. Insurance under the Policy shall take effect only:
a. when the Application has been accepted without modication by RBC Life (applies in the Province of Quebec
only), or in all other provinces (and in Quebec if the Application is accepted with modications), a Policy tendered
for delivery is accepted by the Proposed Owner; and
b. when any and all conditions for the delivery of the Policy to the Proposed Owner have been satised completely,
including but not limited to, RBC Life’s receipt and approval of all amendments, addendums and exclusions
required for the Policy to take effect, signed by me/us within the period provided by RBC Life; and
c. when the full initial premium has been paid; and
d. provided no change in insurability of any Proposed Insured has taken place between the time of Application
and delivery. I/We will immediately advise RBC Life, in writing, of any changes in the answers to the questions
in this Application, including the answers to any telephone interview questions, any other questionnaire(s) and
any paramedical or medical exam (as applicable), between the time of this Application, the completion of any
telephone interview, questionnaire(s) and paramedical or medical exam (as applicable), and the delivery of the
Policy.
3. RBC Life may be entitled to render this Policy and any Temporary Insurance Agreement null and void if there is
misrepresentation or non-disclosure in any part of the Application, including any paramedical or medical exam,
telephone interview or questionnaire completed in connection with this Application that is material to the insurance
risk.
4. The entire contract of insurance shall be the Policy, any attached endorsements, exclusions, amendments,
addendums or documents and all completed parts of this Application, application supplement or questionnaire.
Acceptance of the Policy will constitute agreement to its terms and notication of any changes specied by RBC Life
in the Policy.
5. No statement made to and no information acquired by a representative of RBC Life or an examining physician shall be
attributed to or binding upon RBC Life unless contained in the Application or any related declaration of health-related
evidence of insurability. No one other than an ofcer of RBC Life may (a) alter or modify the terms of this Application
or Policy or (b) waive any rights or requirements of RBC Life.
6. I/We have read the section entitled “Collection and Use of Personal Information” appearing in this Application and
understand and agree to its terms.
7. A copy of the “Consumer Fact Sheet Pre-Notice” has been received and read.
Dated at this day of
(City/Province) (Month/Year)
Signature of Proposed Insured A or Parents/Guardians (tutors* Signature of Proposed Insured B or Parents/Guardians (tutors* in
in Quebec) if Proposed Insured A Is Under Age 16 Quebec) if Proposed Insured B Is Under Age 16 (under age 18
(under age 18 in Quebec) in Quebec)
Signature of Proposed Owner (if different than the Proposed Insureds) Signature of Joint Proposed Owner (If other than Proposed
(If Corporate Owner, include title of signing ofcer; if Trustee Owner, Insured(s) A and/or B)
sign as trustee and identify the trust)
* In Quebec, if there is more than one tutor, all tutors must sign unless one tutor has been given the authority in a specic mandate to act
unilaterally on the child’s behalf.
AGREEMENT
VPS 105596 89604 (10/2019)
Page 23 of 28
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VPS 105596 89604 (10/2019)
Page 24 of 28
AUTHORIZATION
Name of Proposed Insured A Name of Proposed Insured B
I understand and authorize the Company (RBC Life Insurance Company and its reinsurers) to conduct such investigation as is necessary
and to gather personal information concerning me. I understand that the Company will create and maintain les that contain personal
information concerning me. I also understand that access to personal information concerning me will be limited to the employees of, and
other persons engaged by, the Company in performance of their duties, or to the persons to whom I have granted access, in writing, or
to any other person authorized by law. I further understand that, except when the Company can and does lawfully restrict my access
to personal information concerning me, I will be permitted to review copies of documents containing said personal information in the
possession of the Company, upon paying reasonable copying charges. I further understand that I will be permitted to request access
to such documentation and to have any errors in the personal information noted and corrected by formulating a written request to the
Company. I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any
information, records or other data regarding me, my medical history or treatment, or my past and present income or employment that is
relevant to this Application that they have in their possession or control.
Persons to whom this Authorization applies: Any licensed physician, nurse, counselor, psychologist, social worker, therapist, pharmacist,
physiotherapist, chiropractor, or other rehabilitation professional or other healthcare practitioner; and also any hospital, clinic, pharmacy,
or other medical facility or provider of healthcare or treatment; and also the provincial health insurance plan, any insurance or reinsurance
company or other nancial institution; and also my employer or former employers; and also any federal or provincial government
department or organization, including the federal or provincial income tax authorities and provincial motor vehicle divisions; and also
the MIB, Inc.; and also any other person, agency, credit bureau or institution having information, records or data regarding me. This
Authorization to obtain information is valid until revoked by me in writing. If I choose to revoke this Authorization to obtain information,
consequences may include termination of the underwriting process and/or the Policy, if one has been issued.
I understand that any information, records or data received by the Company pursuant to this Authorization, both medical and non-medical,
will be used for the assessment of insurance risk for underwriting purposes; for the purpose of evaluating any claim for benets; assessing
the validity of the Policy as issued; and, issuing and delivering the Policy. Only to the extent reasonably necessary for those purposes, I
authorize the Company to disclose any of the said information, records or data received: to the MIB, Inc.; to other insurance companies, or
any reinsurer; and, to my Servicing Representative, such as my insurance advisor or broker. This Authorization to disclose information as
reasonably necessary is valid until revoked by me in writing.
I authorize the Company to disclose to my Servicing Representative material information regarding my health and personal history solely
for the purpose of explaining underwriting decisions. This disclosure could include history of mental illness, infectious disease, drug and
alcohol use, record of criminal activity, or other facts that have a material effect on the Company’s decision to insure me. This Authorization
to disclose information for this purpose is valid until 60 days after the later of the day the Company issues a new or amends the existing
Policy; or the Company noties me in writing that my Application has been declined, withdrawn, or led incomplete.
Proposed Insured A does not agree to the disclosure of health and personal information to the Servicing Representative
Proposed Insured B does not agree to the disclosure of health and personal information to the Servicing Representative
I also authorize the Company to release to my healthcare professional any medical information obtained for this insurance Application,
including the results of any blood or urine test or urine drug screening tests for the purpose of revealing ndings that might require further
investigation or treatment or for the purpose of explaining any underwriting decision. This Authorization to disclose medical information is
valid until revoked by me in writing. A photocopy of this Authorization, as executed by me, will be as valid as the original. Any alteration of
this Authorization will render it null and void.
Dated at
this day of
(City/Province) (Month/Year)
Signature of Proposed Insured A
Signature of Proposed Insured B
AUTHORIZATION
VPS 105596 89604 (10/2019)
Page 25 of 28
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VPS 105596 89604 (10/2019)
Page 26 of 28
TEMPORARY LIFE INSURANCE APPLICATION
If any of the following questions are answered “Yes,” or left blank and/or if any Proposed Insured is under 15 days of age or over
65 years of age, the Proposed Insured(s) is not eligible to apply for Temporary Life Insurance.
When answering the questions on this form, please do so without reference to any genetic tests you may have taken or are
planning to take. A genetic test is a type of medical test which analyzes DNA, RNA, or chromosomes.
Has the Proposed Insured:
Proposed
Insured A
YES NO
Proposed
Insured B
YES NO
1. ever been treated for or had any indication of heart or circulatory disease, heart attack, high blood
pressure, chest pain, abnormal ECG, stroke, transient ischemic attacks (TIAs), diabetes, chronic kidney,
liver or lung disease, cancer or tumour, multiple sclerosis, paralysis, motor neuron disease, Alzheimer’s
disease, Huntington’s disease, Parkinson’s disease, AIDS, ARC or HIV infection, loss of speech,
blindness or deafness? ..................................................................
2. within the past year, other than normal childbirth, been admitted to a hospital or other medical facility or
been advised to do so? .................................................................
3. been advised to have any tests, investigations or surgery not yet done? ...........................
4. in the past year had any Application for life insurance, change or reinstatement declined, rated or
modied in any way? ...................................................................
Is the Proposed Insured:
5. aware of any symptoms for which they have not sought treatment or for which treatment is planned or
pending? .............................................................................
Dated at this day of
(City/Province) (Month/Year)
Signature of Proposed Insured A or Parents/Guardians (tutors in Signature of Proposed Insured B or Parents/Guardians (tutors in Quebec)
Quebec) if Proposed Insured A Is Under Age 16 (under age 18 in Quebec) if Proposed Insured B Is Under Age 16 (under age 18 in Quebec)
Signature of Proposed Owner (if other than Proposed Insured(s) A and/or B) Signature of Joint Proposed Owner (If other than Proposed Insured(s)
A and/or B)
Temporary Life Insurance Receipt (applicable only if Temporary Life Insurance is applied for)
RBC Life Insurance Company (RBC Life) acknowledges receipt of
$
,
which is at least the minimum payment of
one monthly premium (1/12 of an annual premium if paying annually) at standard rates for the life insurance Policy applied for under this
Temporary Life Insurance Agreement (Life TIA) or authorization has been provided to RBC Life in this Life Insurance Application (Life
Application) to withdraw this sum immediately by pre-authorized debit in payment for coverage under the Life TIA on the life (lives) of
Proposed Insured(s)
Dated at this
day of
(City/Province) (Month/Year)
Signature of Representative
The Temporary Life Insurance Application, the Life Application, and the payment by cheque (if applicable) must all be dated the same
date or the Temporary Life Insurance Agreement is null and void.
Temporary Life Insurance Agreement (Life TIA)
RBC Life Insurance Company (RBC Life) agrees to insure the Proposed Insured specied on the Temporary Life Insurance Receipt,
who, in this Life TIA, will be referred to as the Proposed Insured, subject to the terms and conditions set out below.
Coverage
Temporary life insurance commences once the Life Application and the Temporary Life Insurance Application (Life TIA Application) have
been signed and the payment for coverage under this Life TIA has been received.
In the event of the death of the Proposed Insured (if more than one Proposed Insured, the rst or last to die according to the Life
Application) while this Life TIA is in force and subject to a maximum aggregate liability of $1,000,000 under this and all other Temporary
Life Insurance Agreements issued by RBC Life on the Proposed Insured, RBC Life will pay to the beneciary(ies) designated in the Life
Application the LESSER OF:
a. the amount of life insurance applied for in the Life Application, OR
b. $1,000,000.
If the total amount of life insurance applied for on the Proposed Insured in the Life Application is greater than the maximum payable
under this Life TIA and the Proposed Insured dies while covered under this Life TIA, RBC Life will refund the portion of any payment for
coverage over the maximum payable under this Life TIA for that Proposed Insured.
LEAVE THIS PORTION ATTACHED IF APPLICABLE, DETACH AND GIVE TO PROPOSED OWNER
VPS 105596 89604 (10/2019)
Page 27 of 28
Termination of Temporary Life Insurance
Insurance coverage provided by this Life TIA will terminate on the earliest of:
a. 90 days from the date the Life Application is signed, OR
b. the date on which RBC Life mails notice of termination of insurance under this Life TIA, OR
c. the date the Policy RBC Life issues in response to the Life Application takes effect, OR
d. the date the Proposed Owner(s) refuse(s) to accept delivery or otherwise reject(s) the Policy issued in response to the Life
Application, OR
e. the date the Proposed Owner(s) ask(s) RBC Life to cancel this Life TIA or otherwise withdraw(s) the Life Application, OR
f. the date of death of the Proposed Insured (if more than one Proposed Insured, the date of death of the rst or last to die
according to the Life Application).
Except in the case of fraud, payment received by RBC Life will be refunded in the event of termination under a, b, d or e.
Limitations and Exclusions
a. If there is material misrepresentation or non-disclosure in any part of the Life Application or Life TIA Application, any Application
supplement or questionnaire, or any paramedical or medical exam, no Life TIA will take effect and RBC Life shall, except in the
case of fraud, refund the payment for this Life TIA.
b. RBC Life shall have no liability if the specied Proposed Insured, while sane or insane, commits suicide, except RBC Life shall
refund the payment for this Life TIA.
c. No accidental death rider, disability/income replacement, critical illness, children’s term rider, or return/waiver of premium
benets are provided under this Life TIA.
d. No Life TIA will take effect if any question is answered “Yes” and/or not answered in the Life TIA Application; the Life Application
and/or the Life TIA Application is (are) not signed; the Proposed Insured is under 15 days of age or over 65 years of age; the
payment for coverage under the Life TIA is not honoured on presentation; and/or the date of the Life TIA Application, the Life
Application and the cheque (if applicable) are not dated on the same date.
e. Life TIA is not available if the Life Application is made under any conversion provision of an existing Policy or the conversion
option of a rider to any existing Policy.
LEAVE THIS PORTION ATTACHED
IF APPLICABLE, DETACH AND GIVE TO PROPOSED OWNER
VPS 105596 89604 (10/2019)
Page 28 of 28
REPRESENTATIVE’S REPORT
1. Were the negotiations for this Application started by: You? Proposed Owner(s)? Proposed Insured(s)?
2. Back date to save age? Yes No (Age is calculated based on the age nearest to the underwriting decision date, not
the Application date.)
3. Other special date required?
4. Evidence: The following requirements have been ordered:
Blood Prole ECG/Ex.ECG Medical MVR Paramedical Urine-HIV Vitals
Other Specify
Para-Medical Company Used Specify
5. Representative’s Declaration:
I have clearly explained the provisions and limitations of the Policy being applied for (and the Temporary Insurance
Agreement, if applicable) to the Proposed Insured(s) and the Proposed Owner(s). All of the questions in the Application
were clearly asked of, or read by, the Proposed Insured(s) and the Proposed Owner(s). To the best of my knowledge, they
understood all of the questions. To the best of my knowledge, all of the answers and statements on the Application have
been fully and accurately recorded. I am not aware of any pertinent information about the Proposed Insured(s) that has
not been disclosed on the Application. If a Policy is issued, I will deliver it to the Proposed Owner(s) only after obtaining
conrmation that all conditions for delivery have been completely satised and there has been no change in the insurability
of the Proposed Insured(s). I understand that I cannot modify the Application, the Temporary Insurance Agreement or the
terms of the Policy, if issued. I have complied with my duties and obligations in regard to the Advisor Disclosure, including
providing an Advisor Disclosure Statement in writing to the Proposed Owner(s).
Date (dd/mm/yyyy)
Representative’s Signature
Representative’s Name
Representative’s Company Name
Marketing Ofce/MGA
Share
%
Servicing
Representative Life Code
%
Representative
Life Code
Please use this space for any special instructions or additional information which would be helpful in the underwriting of this risk.
REPRESENTATIVE’S REPORT
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
VPS105596 89604 (10/2019)
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