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Foreign Contract
Employee Questionnaire
This Questionnaire must be completed for each Foreign Contract Employee working for the Employer in Canada for whom group insurance
is being applied. Head Ofce Group Underwriting written pre-approval is required in all cases and will be based on the information provided.
Additional documents may be requested, as required.
Name of Employer:
Name of Employee: Last Name
Occupation:
Date of Birth (Day/Month/Year):
Province of Residence:
Date of Hire (Day/Month/Year):
Citizenship:
Date of Work Permit: Start Date:
Group Policy Number:
First Name
Annual Salary: $
Gender: Male Female
Language: English French
End Date:
(Day/Month/Year) (Day/Month/Year)
What benets is the Employer requesting for this Employee?
The Employee is to be insured in accordance with Class of the group policy(ies).
NOTE: Coverage will be subject to all terms and conditions of the policy(ies), as well as the current Group Underwriting guidelines with respect
to Foreign Contract Employees.
Extension of coverage will be considered based on the following information:
1. Is the Employee working full time, as dened in the Group Policy? ......................................... Yes No
2. Has the Employee applied for all the group benets that are customarily provided by the Employer
to employees in this Employee’s Class? Yes No
3. Is the Employee covered under the provincial government health care plan? ................................. Yes No
If yes, please provide the effective date of coverage (dd/mm/yyyy)
If no, please complete question 4.
4. If the Employee is not covered under the provincial government health care plan, do they have equivalent coverage
through an insurance company? .................................................................... Yes No
If yes, please provide the following details:
Name of insurer:
Name of insurance product (if known):
NOTE: In order to qualify for any coverage, the Employee must be covered under the provincial government health care plan or have the
equivalent coverage through an insurance company. The Employer must also provide the Employee with all of the customary group benets
available to other employees in the Employee’s Class.
Employer’s Authorized Signature: Date:
(Day/Month/Year)
Name and Title (Please print):
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
111015 (01/2020)
VPS 106495
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signature
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