Fillable Form 2.: Loss of Use / Dismemberment Notice (RBC Insurance)

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Form 2.: Loss of Use / Dismemberment Notice (RBC Insurance)

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  • 8 check-boxes
  • 230 other fields

Country of origin: CANADA
File type: PDF

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Loss of Use / Dismemberment
Notice of Claim
VPS 107828
EMPLOYER INSTRUCTIONS
1. Send the Client’s/Employee’s Statement
and the Attending Physician’s Statement
to the Insured.
Complete the Employer’s Statement.
2.
Send these documents to
RBC Insurance at: intake@rbc.com
These forms represent initial notice of claim. Omissions or
errors may cause a delay. Additional documentation may be
requested from RBC Life Insurance Company
(RBC Insurance) upon review of these forms.
Employer’s Statement.
Client’s/Employee’s Statement.
Digital copy of the enrolment form.
CLIENT/EMPLOYEE INSTRUCTIONS
1. Complete the Client’s/Employee’s Statement. Return this form to your Employer.
2. Complete and sign the Authorization section on the Attending Physician’s Statement, and send this form to your treating
physician for completion. The form can be returned directly to our ofce.
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
www.rbcinsurance.com
83762 (10/2020)
Page 1 of 8
VPS 107828
LOSS OF USE / DISMEMBERMENT CLAIM FORM
CLIENT’S/EMPLOYEE’S STATEMENT
To be completed by the Insured Employee, if different from the Client.
SECTION A
Name of Insured Employee:
Last First Middle
Date of Birth: Relationship of Client to you:
(DD/MM/YYYY)
Policy Number: Email address:
SECTION B
To be completed by the Client (Client is the Individual who has suffered the loss, which is the basis of this claim).
A designated representative should complete this form if the Client is unable to do so or if the Client is a minor child.
Mr. Mrs. Ms. Miss Dr. Male Female Social Insurance No.
– –
Name: Date of Birth:
Last First Middle (DD/MM/YYYY)
Address:
Apt. Street City Province Postal Code
Email address:
Telephone No. (H):
( ) Date of Hire:
(DD/MM/YYYY)
Occupation: Length of time in this occupation:
INFORMATION ABOUT YOUR CLAIM
1. What is the basis of your claim?
Accidental Dismemberment. Describe loss:
Loss of: sight hearing speech
Loss of use of:
Paralysis
Permanent & Total Disability
Other:
2. If the claim is for Permanent & Total Disability:
a) What was your last day worked? b) What was the date that you were first unable to work?
(DD/MM/YYYY) (DD/MM/YYYY)
3. a) What was the date of the Accident: Time
AM/PM
(DD/MM/YYYY)
b) Did the Accident occur at home work elsewhere?
c) How did the accident occur?
(If due to an MVA, attach a copy of the accident report and correspondence received from the auto carrier)
1. Date of first treatment by a physician for this condition: (DD/MM/YYYY)
2.
If hospitalized: Name of Hospital(s) Date admitted (DD/MM/YYYY) Date discharged (DD/MM/YYYY)
3. List all other treating physicians:
DIRECT DEPOSIT
Transit No.: Institution No.: Bank Account No.:
Account: Chequing Savings (Credit Line Accounts not accepted)
TREATMENT
I authorize RBC Life Insurance Company (“RBC Insurance”) to deposit my benet payments to the bank account and nancial institution indicated
above, until further written notice from me.
Signature: Date:
*Attach an unsigned digital copy of a cheque marked “VOID”.
83762 (10/2020)
(OVER)
Page 2 of 8
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VPS 107828
FRAUD NOTICE
Any person who knowingly les a Client’s Statement containing false or misleading information is subject to criminal and civil penalties.
I,
(Print Name)
, declare that the above statements are true and complete
to the best of my knowledge and belief.
Date
(DD/MM/YYYY)
Signature of Client
AUTHORIZATION
I understand and authorize the Company (the Company refers to and includes each of RBC Life Insurance Company, RBC Insurance Services Inc., and their
service providers, representatives and their reinsurers) to conduct such investigation as is necessary, to gather personal information concerning me from
third party sources, including the collection of any personal information that is available online, including, without limitation, news websites, social media,
professional or business directories and public registries, and to disclose as necessary to third parties that I am making a claim to the Company for benets
and relevant information concerning that claim. I understand that the Company will create and maintain les, which 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
the performance of their duties, or the persons to whom I have granted access, in writing, or to any other person or organization authorized by law. I have read,
understand and agree with the Global Privacy Notice published at https://www.rbc.com/privacysecurity/ca/global-privacy-notice.html.
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 have any errors in the personal information noted and corrected by formulating a written request
to the Company mailed to the employee who is handling my claim.
I acknowledge and agree that if I choose to use, or instruct the Company to use, any electronic communication that is not encrypted, including without limitation,
any fax or email communication, that (i) security, privacy and condentiality cannot be ensured, (ii) such communication is not reliable and may not be received by
the intended recipient in a timely manner or at all, (iii) such communication could be subject to interception, loss or alteration, and (iv) I assume full responsibility
for the risks in connection with such communication and the Company will not be responsible or liable in any way in connection with such communication,
including without limitation, any unauthorized access to or interception, loss or alteration of such communication.
Your Authorization to Disclose Personal Information
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, employment, education or training, which they have in their possession or control.
Persons to whom this Authorization Applies: Any physician, nurse, counselor, psychologist, pharmacist, physiotherapist, chiropractor or other rehabilitation
professional or other health care practitioner; and also any hospital, clinic, pharmacy, or other medical facility or provider of health care or treatment; and also
the provincial health insurance plan, any insurance company or other nancial institution or insurance broker or administrator; and also my employer or former
employers and any of their agents performing services relating to any employee benets or workers’ compensation; and also any federal or provincial government
department or organization, including the Workers’ Compensation Board/Workplace Safety and Insurance Board, the CPP/QPP disability/retirement authorities,
and the federal or provincial income tax authorities; and also to any other person, agency, credit bureau or institution having information, records or data regarding
me, my medical history or treatment, or my past and present income, employment, education or training.
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 purpose of determining coverage under the policy, evaluating my claim for benets, my ability to return to work and/or for the purpose of assisting with
the co-ordination of my return to work, for the purpose of administering the group and/or individual plans of insurance (including life, accidental death and
dismemberment and disability policies of insurance) arranged through my employer with the Company or another insurer, for the purpose of providing ongoing
claim status information to my employer at the time the claim was incurred, for the recovery of any overpayment of benets incurred by me, if necessary, or for the
purposes of fullling its (or RBC Financial Group’s) obligations or investigations with respect to audits, anti-money laundering, terrorist nancing, fraud detection,
prevention or suppression or other criminal activities. To the extent reasonably necessary for those purposes, I authorize the Company to disclose any of the
said information, records or data received: to other insurance companies or any reinsurer; or to my employer and their insurance brokers or advisors or their
benet plan administrators; or to my physicians or health care providers; or to any other person or organization (including physicians, health care practitioners,
rehabilitation workers, vocational evaluators) employed or engaged by the Company.
I also authorize the Company to collect, use and disclose, as necessary and relevant, my personal information from any prior claim(s) and/or for any subsequent
claim(s).
I also authorize the Company to use my Social Insurance Number for any tax reporting purposes and CPP/QPP purposes and to request information from federal
and provincial tax authorities and for identication purposes when required by policyholders on group LTD/GSI policies.
This authorization does not have any expiry date. It will remain valid for as long as I am claiming eligibility for benets or services from the Company and while
the Company pursues subrogation rights or the recovery of any overpayment of benets incurred by me, if necessary, whether or not benets are being paid,
and whether or not either party takes the position that there has been a breach of contract. A photocopy of this authorization, as executed by me, will be as valid
as the original.
X
Signature of Client
Date:
(DD/MM/YYYY)
Social Insurance Number:
– –
Name of Client (Please Print)
Date:
Signature of Witness (DD/MM/YYYY)
Name of Witness (Please Print)
83762 (10/2020)
Page 3 of 8
X
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VPS 107828
LOSS OF USE / DISMEMBERMENT CLAIM FORM
EMPLOYER’S STATEMENT
EMPLOYER INFORMATION
Name of Employer:
Address (Street/City/Province/Postal Code): Telephone No.
( )
Name of Group Policyholder:
Address (Street/City/Province/Postal Code): Telephone No.
( )
EMPLOYEE INFORMATION
Name (Last, First, Middle):
Social Insurance Number
–
–
Date of Birth:
(DD/MM/YYYY)
Address (Apt/Street/City/Province/Postal Code): Telephone No.
( )
Occupation/Duties: Number of Hours Worked
Per Week:
Employment Status:
Active
Full-time
Part-time
Leave of Absence
Terminated
Medical Leave
Other
Date Employed:
(DD/MM/YYYY)
Effective Date
of Insurance: (DD/MM/YYYY)
Last Date of
Active Work: (DD/MM/YYYY)
Claim is for: Employee Employee’s Spouse Employee’s Dependent Child
Identication of Injured Party (if other than employee):
Name (Last, First, Middle): Date of Birth:
(DD/MM/YYYY)
Address (Apt/Street/City/Province/Postal Code): Social Insurance Number
– –
Date of Accident: Any other insurance in force?
(DD/MM/YYYY)
(Provide amounts and names of insurance carriers and policy numbers)
Is the condition due to an injury or sickness arising out of insured’s employment? Yes No Unknown
Amount of Insurance in force $
If based on earnings, rate of basic earnings $ Hourly Weekly Monthly Annually
(Attach verification of earnings i.e. payroll listing, paystub)
Type of Insurance Policy No. Amount Effective Date Beneficiary
Basic
Voluntary
Travel
Have premiums terminated? Yes - give date (DD/MM/YYYY) No
SIGNATURE
Signature of Representative
Title of Authorized Representative Telephone No.
( )
Group Policy No(s). Division No. Class No.
Date
(DD/MM/YYYY)
83762 (10/2020)
Page 4 of 8
X
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VPS 107828
Describe the onset of the condition:
Was the loss due solely to an accident:
X
LOSS OF USE / DISMEMBERMENT CLAIM FORM
ATTENDING PHYSICIAN’S STATEMENT
AUTHORIZATION
Patient Name Age Policy No(s). Employer Name
I hereby authorize the release to RBC Life Insurance Company, and its service providers, representatives and its reinsurers any information requested in
respect to this claim.
Signature of Client/Patient Date (DD/MM/YYYY)
(If the claim is for a minor child, the signature is for the legal guardian)
Note: The Patient is responsible for securing completion of this form and any charge for its completion.
PATIENT INFORMATION
Name:
Last First Middle
Date of Birth:
(DD/MM/YYYY) Height (in/cm) Weight (lb/kg)
DIAGNOSIS
1. a) Diagnosis and brief description of the condition:
b)
c) Yes
If “Yes,” provide: Date of accident:
(DD/MM/YYYY)
If “No,” what disease or condition was a contributory cause?
No
First visit for this condition:
(DD/MM/YYYY)
d) Objective findings: (include the name of tests, the date performed and the results)
2. Provide names of any other physicians who treated the insured for a contributory condition:
Name of Physician Address Date(s) seen
3.
Is the condition due to an injury or sickness arising out of the insured’s employment?
Yes No Unknown
4.
a) Is the loss total and irrecoverable? Yes No
b) Is improvement possible with any assisting devices? Yes No
Comments:
The following pages contain condition-specic questions, so complete only those applicable.
(OVER)
83762 (10/2020)
Page 5 of 8
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VPS 107828
Extent of visual acquity before and after the accident (Snellen Notation):
Extent of hearing before and after the accident:
Indicate when the loss occured:
5. For vision (if applicable):
a) Date of latest eye examination before the accident:
first examination after the accident:
(DD/MM/YYYY) (DD/MM/YYYY)
b)
With corrective devices, before/after: O.D. O.S.
Without corrective devices, before/after: O.D. O.S.
c) Date corrected vision was irrecoverably reduced to 20/20 or less (Snellen Notation): O.S. (DD/MM/YYYY)
O.S. (DD/MM/YYYY)
d) Is there a visual field defect? Yes No If “Yes,” give details and degree of remaining field:
O.D.
O.S.
e) Prognosis:
Vision can be restored in whole or in part by: Lenses Treatment Surgery No restorable
If by surgery, do you recommend it? Yes No
If “No,” why?
6. For hearing (if applicable):
a) Date of latest hearing examination before the accident:
b)
With corrective devices, before/after:
Without corrective devices, before/after:
c) Prognosis: Hearing can be restored in whole or in part by:
If by surgery, do you recommend it?
If “No,” why?
(DD/MM/YYYY)
Devices
Yes
first examination after the accident:
Right Ear Left Ear
Right Ear Left Ear
Treatment Surgery
No
(DD/MM/YYYY)
No restorable
7. For paralysis / loss of use (if applicable):
a)
Indicate: Quadraplegia Hemiplegia
b) Indicate whether this is complete or incomplete:
c) Indicate what caused the paralysis/loss of use:
Paraplegia other:
d)
83762 (10/2020)
Page 6 of 8
VPS 107828
ATTENDING PHYSICIAN’S STATEMENT
8. For loss of limb/ngers/toes/etc. (if applicable):
a) Indicate exact point of severance
Left Upper
Right Upper
Left Lower
Right Lower
b) Date of severance
(DD/MM/YYYY)
(DD/MM/YYYY)
(DD/MM/YYYY)
(DD/MM/YYYY)
Remarks: Please provide comments and further details that you feel would be helpful.
SIGNATURE
Signature of Representative
X
Signature Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name
Primary care Consultant
Address (Street/City/Province/Postal Code)
( ) ( )
Telephone No. Fax No.
Send the completed form and documents to our ofce by email: intake@rbc.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
www.rbcinsurance.com
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
83762 (10/2020)
Page 7 of 8
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VPS 107828
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 also collect information from third party
resources, including the collection of any personal information that is available online, including, without limitation, news websites,
social media, professional or business directories and public registries, and resources. 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. If you are insured under a group insurance policy obtained through
your employer, we may also share your information with your employer when necessary for the services we provide to you. Your health
information will not be shared with your employer without your consent.
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 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 and (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.
If we have your social insurance number, we may use it for tax related purposes and share it with the appropriate government
agencies.
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 or to ask
questions about our privacy policies, 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 web site at www.rbc.com/privacysecurity.
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
83762 (10/2020)
Page 8 of 8
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Form 2.: Loss of Use Dismemberment Notice (RBC Insurance)

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Completed 21 May 2021

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