Fillable Group Enrollment Form (RBC Insurance)

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Group Enrollment Form (RBC Insurance)

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  • 8 check-boxes
  • 110 other fields

Country of origin: CANADA
File type: PDF

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VPS 105596
83576 (11/2019)
Group Enrollment Form
For RBCI Head Ofce Use Only
OCC Code
Complete this form to enrol for employee benefits. Refer to the third page of this form for important instructions on how to accurately complete
each section.
EMPLOYER SECTION (to be completed by an authorized Plan Administrator)
New Applicant
Reinstatement
Name of Employer RBCI
Policy No.
Billing
Division No.
Plan Member ID No.
(if reinstated)
Alternate ID No.
(if applicable)
Province of
Employment
Employment Date
(yyyy/mm/dd)
Class
No.
Occupation Earnings:
Hr Mth
$
Wk Yr
No. of Hours
Worked/Week
EMPLOYEE SECTION (to be completed by the employee)
Plan Member Last Name First Name Initial Date of Birth
(yyyy/mm/dd)
Gender: Male Female
Language: English French
Home Mailing Address City Province Postal Code Number of
Dependents
Marital Status: Single Married Common-Law*
* I hereby certify that I have been living with my common-law partner since (yyyy/mm/dd)
Are you a Canadian Citizen or a Permanent Resident (landed immigrant)? Yes No
If “no”, a Foreign Contract Questionnaire is required to be completed and submitted with your enrolment form. Please contact your Plan Administrator or
Human Resources Representative.
REFUSAL OR CO-ORDINATION OF BENEFITS SECTION
(to be completed by the employee only if Health and/or Dental is part of your Group Benet Contract)
If you and/or your dependents are presently covered for Health and/or Dental Coverage under your spouse’s Group Benet Contract, you may refuse to be
covered for such benets under this Contract or Co-ordinate Benets.
I understand the plan of group benets offered to me, but I wish to:
Health Coverage:
Decline coverage for myself and my dependents Decline coverage for my dependents Co-ordinate benets
Dental Coverage:
Decline coverage for myself and my dependents Decline coverage for my dependents Co-ordinate benets
Name of Your Spouse’s Group Insurer Start Date of Coverage (yyyy/mm/dd)
To add these benets at a later date, you must apply for coverage within 31 days of the loss of spousal coverage. If you do not apply within 31 days, you
and your dependents may be required to provide proof of insurability, and coverage may be restricted or denied.
RBC Life Insurance Company
PO Box 1600, 8677 Anchor Drive
Windsor ON N9A 0B3
1-855-264-2174
www.rbcinsurance.com
VPS 105596
83576 (11/2019)
DEPENDENT ENROLMENT INFORMATION SECTION
(to be completed by the employee only if Health and/or Dental is part of your Group Benet Contract)
Health Coverage: Single Couple Family Single Parent Waived
Dental Coverage: Single Couple Family Single Parent Waived
If there are more than four dependents, please attach a separate list.
Dep. Last Name First Name Initial
Date of Birth
(yyyy/mm/dd)
Gender
(M/F)
Full-Time
Student
Over-Age
Disabled
Dependent
Spouse
1st Child
2nd Child
3rd Child
4th Child
BENEFICIARY DESIGNATION SECTION
(to be completed by the employee for Life Insurance and Accidental Death Benets)
Beneciary’s Last Name First Name Initial
Date of Birth
(yyyy/mm/dd)
Gender
(M/F)
Relationship %
FOR RESIDENTS
OF QUEBEC ONLY:
A spousal beneciary
designation is irrevocable
unless otherwise
specied. If your spouse
is the beneciary, the
designation is:
Revocable
Irrevocable
If the beneciary is a minor or lacks legal capacity, an Appointment of Trustee is recommended in all provinces, except Quebec.
Trustee (Last Name, First Name) Relationship to Employee
is hereby appointed Trustee to receive any payment due to any designated beneciary on record with RBC Life Insurance Company who is a minor on the
date such payment falls due.
OPTIONAL LIFE SECTION
(to be completed by the employee only if Optional Life is part of your Group Benet Contract)
The Evidence of Insurability form is required when applying for this benet; please attach it to this form.
Amount of Coverage Selected for: You $ Spouse $ Each Child $
AUTHORIZATIONS AND DECLARATIONS
(to be signed by both an Authorized Plan Administrator and the employee)
By signing this enrolment form and providing my personal information to my employer, I conrm that the information is complete and accurate to the best of my
knowledge. I authorize my employer to share my personal information and my spouse’s and dependent’s personal information with my employer’s third-party
administrator and with RBC Life Insurance Company and its service provider in order to administer the insurance coverage. I certify that I am authorized by
my spouse and/or dependents to disclose and receive information about them that is used for these purposes.
I hereby apply for group insurance coverage for which I am now or may later become eligible and authorize my employer to deduct the required contribution,
if any, from my pay. I agree that any insurance issued as a result of this application shall take effect on the date I am actively employed on a full-time basis,
otherwise on the date I return to full-time active employment, subject to approval by RBC Life Insurance Company and any waiting period pertinent to my
employer’s plan. RBC Life Insurance Company shall not be liable for any claim commencing prior to the effective date of insurance.
Plan Administrator Signature Date (yyyy/mm/dd)
Plan Member Signature Date (yyyy/mm/dd)
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VPS 105596
83576 (11/2019)
INSTRUCTIONS
Complete each section according to the instructions listed below and sign the bottom of the form when you are
sure that the information is complete and accurate. Incorrect or incomplete enrolment information could result in
denial or improper payment of your claims.
EMPLOYER SECTION
1. Mark the appropriate box to indicate if the employee is new or is applying to be reinstated.
2. Please record the Plan Member ID No. only if you are applying to reinstate that member.
3. Please record the Alternate ID No. (9 characters) if you would like to uniquely identify a plan member (e.g. Cost Centre, Badge Number).
4. Please record the province of employment.
5. Please record the date when full-time or part-time employment commenced.
6. If your Group Benet Contract is different for classes of employees (e.g. union/non union, management/staff), please indicate the classication the
employee falls into.
7. Please record the employee’s occupation.
8. Please record the employee’s earnings (as per the denition of earnings in your Group Benet Contract), payment period and number of hours
worked each/every week.
EMPLOYEE SECTION
1. Print your name and full mailing address in the designated areas. Please record the rst name you will use when you submit claims as this name will
also appear on your Group Benet Card (e.g. if you will use Robert when you submit a claim, do not use Bob when completing this form).
2. Enter date of birth, then mark the appropriate box to indicate gender and language.
3. Please record the number of dependents.
4. A marital status of common-law means that you have been living with your common-law partner for a continuous period of at least 12 months.
REFUSAL OR CO-ORDINATION OF BENEFITS SECTION
To be completed ONLY if Health and/or Dental Coverage is part of your Group Benet Contract
1. If you are eligible for Health and/or Dental Coverage through your spouse’s Group Benet Contract, you can either refuse to be covered for such
benets under this Contract or request co-ordination of benets by selecting the applicable box.
2. Please record your spouse’s group insurer and the start date of that coverage.
DEPENDENT ENROLMENT INFORMATION SECTION
To be completed ONLY if Health and/or Dental Coverage is part of your Group Benet Contract
1. For Health and/or Dental Coverage please indicate your family status by checking the appropriate box (Single, Couple, Family, Single Parent or
Waived).
2. Print the names in full of each dependent eligible to be covered under your employer’s Group Benet Contracts. Be sure to use the rst name that
will be used when submitting claims, as this name will also appear on your Group Benet Card (e.g. if you will use Betty when you submit a claim,
don’t use Elizabeth when completing this form).
3. Enter the full date of birth for each dependent. Please conrm the accuracy of these birth dates since they will affect claims payment and dependent
eligibility.
4. Enter “M” (male) or “F” (female) to identify the gender of each dependent.
5. If your dependent is an over-age adult dependent (as dened in your Group Benet Contract), please check the appropriate box (Full-Time Student
or Over-Age Disabled Dependent).
BENEFICIARY DESIGNATION
1. For Quebec residents, if your spouse is your beneciary, then you must designate your beneciary as either “Revocable “or “Irrevocable.” If you
do not indicate “Revocable” it will be assumed (per provincial legislation) that your spouse is your “Irrevocable” beneciary. Revocable: you may
change your beneciary (per the Group Benet Contract) without the written consent of the current beneciary. Irrevocable: you may not change
your beneciary (per the Group Benet Contract) without the written consent of the current beneciary.
2. Please ensure that you have indicated your beneciary’s relationship to you and the percentage. For multiple beneciaries, the percentages must
total 100%.
OPTIONAL LIFE SECTION
To be completed ONLY if Optional Life is part of your Group Benet Contract
1. An employee must be insured for Group Basic Life Insurance in order for the employee, spouse or his/her dependents to be insured for this benet,
and an Evidence of Insurability Form is required when applying for the Optional Life Benet.
PLAN ADMINISTRATOR INSTRUCTIONS
Please keep the original version of the signed Group Enrolment form in your les and use the Online Administration tool to register the employee.
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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Group Enrollment Form (RBC Insurance)

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Completed 21 May 2021

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