73531 (05/2009)
GROUP ACCIDENT INSURANCE
CONVERSION NOTICE
PART I – TO BE COMPLETED BY THE POLICYHOLDER
NAME OF POLICYHOLDER
NAME OF DIVISION
GROUP POLICY NUMBER(S)
BASIC PLAN
GSR
VOLUNTARY PLAN
GSR
OTHER PLAN
GSR
NAME OF APPLICANT
DATE OF BIRTH
/
(DD) (MM)
/
(YY)
AMOUNT OF INSURANCE
$
$
(Basic Plan)
(Voluntary Plan) Single Family
TERMINATION DATE OF
GROUP INSURANCE
Signed for the Policyholder by:
(Title) (Date)
PART II – INSTRUCTIONS FOR APPLICANT
The termination date of your Group Accident Insurance is as stated above. The Conversion Privilege of the Group Policy
provides an opportunity for those persons leaving the Group, who are under the age of 70 years and a resident of Canada,
to convert to an individual accident insurance policy. Application for this provision must be made within 31 days of the
termination date.
You may select an amount of insurance equal to or less than the amount shown in Part I, subject to a maximum amount of
$100,000. Premium is payable on an annual basis. The applicable rates for each $1,000 of insurance you convert are
indicated below, subject to a minimum premium requirement of $100 annually.
Insurance Plan Annual Rates per $1,000
Insured Only $2.00
Insured & Family $2.75
Insured & Children $2.25
The converted policy will be effective the date your Group Accident Insurance terminates, provided completed
Application is received by RBC Life Insurance Company, and will provide a Schedule of Benefits similar to that under
your Group Accident Insurance (disability and expense reimbursement benefits are not included).
If you wish to convert your coverage, simply complete the attached Application for Accident Insurance Conversion and
mail this notice, your completed Application and a fully provisioned cheque or money order to cover the annual
premium or two cheques to cover the semi-annual premium to the address shown below. Conversion notices
postmarked more than 31 days after the termination date of your Group Accident Insurance will be subject to approval of
satisfactory evidence of insurability.
Postdated cheques are not acceptable. Payment by certified cheque or money order is recommended as the Application
will not be approved for coverage if the cheque is not honoured by the bank.
RBC LIFE INSURANCE COMPANY
PO BOX 1800 STN B
MISSISSAUGA, ON L4Y 3W6
ATTENTION: ID CUSTOMER SERVICE
® Registered trademarks of Royal Bank of Canada. Used under licence.
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