Fillable Group Insurance Evidence of Insurability Form SECTION 1: (RBC Insurance)

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Group Insurance Evidence of Insurability Form SECTION 1: (RBC Insurance)

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The Group Insurance Evidence of Insurability Form SECTION 1: (RBC Insurance) form is 16 pages long and contains:

  • 6 signatures
  • 61 check-boxes
  • 332 other fields

Country of origin: CANADA
File type: PDF

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101398 (12/2019)
VPS105596
Group Insurance
Evidence of
Insurability Form
Please answer all applicable questions; all subsequent changes must be initialled by the Employee. On completion, the form must be
signed and dated to be accepted.
IMPORTANT:
The Employee must be a permanent resident of Canada with Canadian Citizenship or Permanent Resident status, and must be an eligible employee
of the Policyholder in Active Employment as dened in the Group Insurance Policy on the date this Evidence of Insurability Form is signed.
SECTION 1: EMPLOYER INFORMATION (to be completed by authorized Plan Administrator)
REASON FOR SUBMISSION OF EVIDENCE OF INSURABILITY BY EMPLOYEE:
New Employee – Eligible for an amount exceeding Non-Evidence Maximum
Optional Life
Add Dependant
Current Employee – Eligible for increase over Non-Evidence Maximum
Late Application
Other:
Name of Company: Group Policy No:
Head Ofce Mailing Address: City: Prov: Postal Code:
Company Phone No: Authorized Personnel:
Billing Type:
Insurer-Billed Self-Billed TPA – Name of TPA:
SECTION 2: EMPLOYEE INFORMATION (to be completed by Employee)
Language Preference:
English
French
Full Legal Name: First:
Initial: Last:
Date of Birth: Gender:
M
F
(day/month/year)
Employee Home Address: City: Prov: Postal Code:
Date of Hire: Occupation: Annual Earnings: $
(day/month/year)
Name and Address of Personal Physician:
Name:
Address:
Please provide the date, reason and results of your last consult with any physician:
Eligible Dependent Spouse
Full Legal Name: First:
Initial: Last:
Date of Birth: Gender:
M
F
(day/month/year)
Name and Address of Personal Physician
(if different from Employee):
Name:
Address:
RBC Life Insurance Company
6880 Financial Drive, Tower 1, Eighth Floor
Mississauga, Ontario L5N 7Y5
1-855-264-2174
www.rbcinsurance.com
Page 1 of 11
101398 (12/2019)
VPS105596
Applying for: $
Applying for:
Applying for:
$
$
Applying for: $
Yes
Please provide the date, reason and results of your last consult with any physician:
Eligible Dependent Child(ren)
First Name
(also indicate last name if different from Employee)
Gender
Date of Birth
(day/month/year)
SECTION 3: COVERAGE (Check all that apply)
Employee Dependant
Basic Life: Basic Dependent Life:
Applying for: Spouse: $ Child: $
Optional Life: Optional Life:
Applying for: Spouse: $ Child: $
Extended Health Care Extended Health Care
Dental Care Dental Care
Short Term Disability:
Long Term Disability:
SECTION 4: HEALTH AND LIFESTYLE QUESTIONS
The following questions must be answered by the applicable Employee and/or Spouse. ALL QUESTIONS MUST BE ANSWERED.
If the answer is “Yes” to any of the following questions, please circle the condition and provide full details in the space provided on page 4,
including dates, duration, treatment, result and name of attending physician.
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.
Employee Spouse
(if applicable)
1
Have you ever had any indication of, been told you have, or have you ever received
treatment or advice for:
a
Abnormal blood pressure, chest pain, heart attack, phlebitis, or any other disease or disorder of the
heart or blood vessels?
If yes to abnormal blood pressure, please complete the following:
Date rst advised of blood pressure: _____________ Treatment:
Diet
Medicine
Other
How long on treatment? ________________ Still in treatment?
Yes
No
In the past two (2) years, have special tests been done?
Yes
No If yes, give type of tests,
dates and results: ______________________________________________________________
Do you have recent readings?
No If yes, give readings: ______________________
Yes
No
Yes
No
Page 2 of 11
101398 (12/2019)
VPS105596
Employee Spouse
(if applicable)
b
Gastrointestinal disorder, ulcer, jaundice, chronic diarrhoea, gall bladder, hepatitis or liver disease/
disorder, or any other disease or disorder of the stomach, intestines or rectum? If yes, complete the
following:
Ulcer
Other: __________ Date of rst attack: _________________ No. of attacks: _______
Treatment:
Medicine – Give name: _______________________
Operation – Give date: _____________
Do you now have symptoms?
Yes
No Are you under treatment?
Yes
No
Yes
No
Yes
No
c
Asthma, bronchitis, emphysema, tuberculosis or any other respiratory disease or disorder?
Yes
No
Yes
No
d
Abnormal urine, venereal disease, or any disease or disorder of the kidneys, bladder, prostate or
reproductive organs?
Yes
No
Yes
No
e
Back or neck pain, whiplash, or any other disease or disorder, injury or deformity of the spine?
If you answer yes to this question, please complete the “Back and Neck Disorder Questionnaire”
on page 5.
Yes
No
Yes
No
f
Arthritis, amputation, or any disease or disorder of the hip, knee, or other joints, bones or muscles,
including brositis or bromyalgia?
Yes
No
Yes
No
g
Epilepsy, paralysis, stroke, recurrent headaches, or any other disease or disorder of the brain or
nervous system?
Yes
No
Yes
No
h
Nervous disorder, anxiety, depression or any stress related illness?
If Yes, please complete the “Mental Health Questionnaire” on page 7.
Yes
No
Yes
No
i
Diabetes, thyroid or other glandular disorder?
Yes
No
Yes
No
j
Cancer, cyst, tumour or skin disease?
Yes
No
Yes
No
k
Anaemia, leukaemia, or any other disease or disorder of the blood or lymph nodes?
Yes
No
Yes
No
l
Any disease or disorder of the eyes, ears, nose or throat?
Yes
No
Yes
No
2
Have you ever had any indication of, been told you have, or have you ever received treatment
or advice for AIDS (acquired immune deciency syndrome), ARC (aids related complex), or any
immunological disorder; or had a positive blood test for antibodies to HIV (human immunodeciency
virus)?
Yes
No
Yes
No
3
a
In the last ve (5) years, have you been examined by or consulted a physician or other health care
professional, received advice, treatment or medication, or been hospitalized for any disease or
disorder not included in Question #1, on pages 2 and 3?
Yes
No
Yes
No
b
Have you ever been advised to undergo investigation or have treatment, testing or consultation which
has not yet been completed, or are you aware of any symptom, complaint or health-related disorder for
which you have not yet sought treatment or consulted a health care professional?
Yes
No
Yes
No
c
In the last two (2) years, have you had any illness or injury which resulted in your absence from
work for ten (10) consecutive days or more?
Yes
No
Yes
No
d
Are you currently receiving any medical advice, treatment or medication?
Yes
No
Yes
No
4
Do you currently participate in any hazardous activities such as auto racing, hang gliding,
rock climbing, aircraft ying or SCUBA diving below 50 feet?
Yes
No
Yes
No
5
Height and Weight:
Employee’s Current Height: _______________
ft/in
cm
Employee’s Current Weight: _______________
lb
kg
If any change in weight of more than 15 lb/7 kg in the past 12 months, state amount
and reason: ____________________________________________________________________
Spouse’
s Current Height: _______________
ft/in
cm
Spouse’s Current Weight: _______________
lb
kg
If any change in weight of more than 15 lb/7 kg in the past 12 months, state amount
and reason:
Page 3 of 11
101398 (12/2019)
VPS105596
Employee Spouse
(if applicable)
6
a Have you ever had any application for life, disability, health or any other form of insurance
(whether Individual or Group) declined, postponed, rated, cancelled or modied in any way?
If yes, provide date(s), reason(s) and name(s) of insurance company(ies).
Yes
No
Yes
No
b Have you ever received benets, compensation or pension because of an illness or injury?
Yes
No
Yes
No
7
In the past 12 months have you used cigarettes, e-cigarettes, vaping products, more than one
large cigar per month, water pipes, betel nuts more than once per month, smoking cessation
products or nicotine or tobacco in any other form?
Yes
No
Yes
No
8
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?
Yes
No
Yes
No
9
Have you ever been advised to reduce your alcohol consumption or been treated for the
excessive use of alcohol?
Yes
No
Yes
No
10
Have you any family history of an inherited or familial disease or condition, including heart or
kidney disease, stroke, diabetes, cancer, multiple sclerosis, Alzheimer disease, Huntington
disease or motor neuron disease?
Yes
No
Yes
No
11
a
This question is for a Female Employee or Female Spouse (if applicable):
Have you ever had a miscarriage, preeclampsia, toxaemia, caesarean section or other
complication of pregnancy?
Yes
No
Yes
No
b Are you currently pregnant? If yes, provide expected delivery date.
Yes
No
Yes
No
12
This question is for Employees applying for Dependant Coverage:
Have any of your eligible Dependent Children been treated for or been given any indication
of having any of the following: heart trouble, high blood pressure, cancer or tumours, kidney
problems, disease or disorder of the stomach, back problems, a nervous or mental condition,
respiratory problems, AIDS, alcoholism, drug dependency, or any other physical or mental
disorder?
Name of child, condition, date and treatment:
(Employee to Respond)
Yes
No
Details of “Yes” Answers
Question
Number
Details Date
(dd/mm/yyyy)
Attending Physician’s
Name and Address
Page 4 of 11
101398 (12/2019)
VPS105596
Back and Neck Disorder Questionnaire
If you answered Yes to question 1e, please complete this questionnaire.
1
Have you ever had any type of back or neck pain or discomfort or any other neck or back related symptom or
complaint or have you ever had any indication of or been treated for any disease or disorder of the back or neck?
If yes, please answer all questions below.
Yes
No
2
Specify area involved:
Neck (cervical)
Upper/middle (thoracic)
Low (lumbar – waist and below)
If more than one area is involved, please complete a separate questionnaire for each area affected.
The following details relate to the
Neck (cervical)
Upper/middle (thoracic)
Low (lumbar – waist & below)
3
a How many episodes of back or neck pain or discomfort or related symptoms have you had?
b Date of rst episode:
c Describe symptoms of the rst episode:
d How long did the symptoms of the rst episode last?
e What was the nal diagnosis?
f Date of the last episode:
g Describe the symptoms of the last episode:
h How long did the symptoms of the last episode last?
i What was the nal diagnosis for the last episode?
j What was the longest duration of symptoms for all episodes?
4
Have you ever had any back or neck related numbness or tingling or radiation of pain to other parts of your body?
If yes, indicate date(s) and area(s) involved:
Yes
No
5
a Have any diagnostic tests been completed?
If yes, specify type(s), date(s), and results:
X-ray studies
CT scan
MRI
Bone scan
Other (specify)
Yes
No
b Have any tests or investigations been recommended?
If yes, specify nature of test(s) or investigation(s) and date(s) scheduled:
Yes
No
6
a Have you ever had epidural steroid injections or treatment at a pain clinic?
If yes, indicate date(s) and name(s) and address(es) of doctor(s) or medical facility(ies):
Yes
No
b Have you ever had chiropractic manipulation or treatment?
If yes, provide details:
1. Date(s), frequency and duration of treatment: ____________________________________________________
2. Date of last chiropractic consultation: ___________________________________________________________
3. Name and address of chiropractor(s): ___________________________________________________________
Yes
No
c Have you ever had physical therapy or any other form of treatment for this condition?
If yes, indicate type(s), date(s) and duration of treatment, name(s) and address(es) of provider(s):
Yes
No
(continued on following page)
Page 5 of 11
101398 (12/2019)
VPS105596
Back and Neck Disorder Questionnaire, continued
7
Have you ever been prescribed medication for any back or neck condition or symptom?
If yes, provide details including name(s) of medication(s) and date(s) prescribed:
Yes
No
8
Have you ever been hospitalized for any back or neck condition or symptom?
If yes, indicate date(s), duration, reason, name and address of hospital(s):
Yes
No
9
Have you been told you may need surgery at some time in the future?
If yes:
a) Specify type of surgery: _______________________________________________________________________
b) Has surgery been scheduled? If so specify date: ____________________________________________________
Yes
No
10
Have you ever lost any time from work due to back or neck related symptoms?
If yes, provide details including dates and duration of time off work:
Yes
No
11
Have your job duties or daily activities ever been restricted or modied in any way because of this condition?
If yes, describe restrictions, modications or limitations:
Yes
No
12
Do you have any ongoing symptoms?
If yes, describe symptoms:
If no, how long have you been completely free of any neck or back related symptoms? ______________________
Yes
No
13
Other than those already declared, please provide the full names and addresses of all doctors, health care professionals,
hospitals or health care facilities consulted for this condition and the dates of consultations:
Page 6 of 11
101398 (12/2019)
VPS105596
Attention decit disorder
Mental Health Questionnaire
If you answered Yes to question 1h, please complete this questionnaire.
1
Please specify/describe all current and past symptoms, history or diagnosis of (tick off appropriate boxes):
Stress
Fatigue, exhaustion
Marriage/family counselling
Bipolar disorder
Anxiety
Chronic fatigue
Suicidal thoughts or attempts
Depression
Major depression
Concentration problems
Psychosis/hallucinations
Burn out
Panic attack(s)
Memory problems
Anger management problems
Insomnia
Adjustment disorder
Agoraphobia
Seasonal affective disorder
Dysthymia
Bulimia
Post traumatic stress
Generalized anxiety disorder
Phobia(s)
Anorexia nervosa
Counselling for (specify): ____________________________________________________
Other (describe):
2
Have you experienced any symptoms within the last 12 months?
If yes, describe all symptoms:
If no, how long have you been completely symptom-free? ______________________
Yes
No
3
a) Date of onset of your initial symptoms: __________________________________________________________________________
b) Cause(s) of symptoms
c) How many separate occurrences or episodes of symptoms have you had? _____________________________________________
d) What was the duration of each occurrence or episode?
4
Has your physician given you a diagnosis?
If yes, provide full details, including the date a diagnosis was given:
Yes
No
5
Have you taken medication, prescribed or non-prescribed, or received treatment in the past 12 months?
If yes, provide the name of all medication(s), the date medication(s) was rst prescribed, details of all treatment and
the date treatment was rst recommended:
Yes
No
6
What other medication(s) or treatment has been prescribed in the past? Provide the name of all medication(s), the date medication(s)
was rst prescribed, details of all treatment, the date treatment was rst recommended, and the date and reason medication(s) or
treatment was discontinued:
7
Have you been referred to a psychiatrist or psychologist for this condition?
If yes, provide full name(s) and address(es) of those consulted, date of rst consultation, frequency of
follow-up visits and date of the last consultation:
Yes
No
8
Have you ever consulted an emergency room or been hospitalized for this condition?
If yes, provide date(s), reason(s) and name and address of hospital(s):
Yes
No
(continued on following page)
Page 7 of 11
101398 (12/2019)
VPS105596
Mental Health Questionnaire, continued
9
Have you ever had any suicidal thoughts or attempts?
If yes, provide dates and details:
Yes
No
10
Have you ever lost any time from work due to this condition?
If yes, provide details including dates and duration of time off work:
Yes
No
11
Have your job duties or daily activities ever been restricted or modied in any way because of this condition?
If yes, describe restrictions, modications or limitations:
Yes
No
12
Other than those already declared, please provide the names and addresses of all physicians, psychiatrists, psychologists, counsellors,
mental health care providers, other health care practitioners, hospitals or facilities consulted for this condition and include details and
duration of treatment:
Page 8 of 11
101398 (12/2019)
VPS105596
SECTION 5: DECLARATION
EMPLOYEE STATEMENT
I hereby declare that the above answers and statements that I have given in this Evidence of Insurability Form are, to the best of my
knowledge and belief, full, complete and true as of this date, and that any misstatements or failure to report information may be used
as the basis for a rescission of my insurance. I understand and agree that they are material to the risk and form part of the Application
and consideration for the insurance I am applying for. I further understand that if the insurance applied for becomes effective, it will be
subject to the terms and conditions of the group policy.
Signature of Employee: ____________________________________________ Date: ______________________
SPOUSE STATEMENT (if applicable)
I hereby declare that the above answers and statements that I have given in this Evidence of Insurability Form are, to the best of my
knowledge and belief, full, complete and true as of this date, and that any misstatements or failure to report information may be used
as the basis for a rescission of my insurance. I understand and agree that they are material to the risk and form part of the Application
and consideration for the insurance I am applying for. I further understand that if the insurance applied for becomes effective, it will be
subject to the terms and conditions of the group policy.
Signature of Employee’s Spouse: ____________________________________ Date: ______________________
SECTION 6: AUTHORIZATION FOR DISCLOSURE OF INFORMATION
I understand and authorize RBC Life Insurance Company and its reinsurers (hereinafter collectively referred to as “RBC Life”) to gather
personal information concerning me and to disclose, as necessary, to third parties the fact that I am seeking insurance coverage from
RBC Life.
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to RBC Life any information,
records or other data regarding me and my medical history or treatment, or my past and present income or employment, 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; and also any federal or provincial government department or organization, including the Workers’ Compensation
Board/Workplace Safety and Insurance Board and the federal or provincial income tax authorities; and also to any other organization,
institution or person having information, records or data regarding me, my medical history or treatment or my past and present income
and employment.
I understand that any information, records or data received by RBC Life pursuant to this authorization will be used for the purpose of
determining eligibility for coverage under group insurance offered by my employer (underwriting), for the purpose of administering the
group insurance policy(ies) arranged through my employer or for the evaluation of any claim for benets.
To the extent reasonably necessary for this purpose, I authorize RBC Life to disclose any of the said information, records or data
received to other insurance companies or any reinsurer; or to my employer and its insurance brokers or advisors or its benet plan
administrators; or to any other person or rm employed or engaged by RBC Life.
If this application is being made on behalf of my dependant(s), I am authorized to disclose information about them, for the purposes of
underwriting, administration or adjudication of claims. I conrm that RBC Life is authorized to disclose information about this application
to me, for the purposes of assessing this application and managing my group benets plan.
A photocopy of this authorization, as executed by me, shall be as valid as the original and shall continue to have effect throughout the
duration of my coverage under the group coverage offered by my employer.
Signature of Employee: _________________________________________________ Date: _________________
Signature of Employee’s Spouse (if applying): _______________________________ Date: __________________
Page 9 of 11
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101398 (12/2019)
VPS105596
SECTION 6: AUTHORIZATION FOR DISCLOSURE OF INFORMATION
I understand and authorize RBC Life Insurance Company and its reinsurers (hereinafter collectively referred to as “RBC Life”) to gather
personal information concerning me and to disclose, as necessary, to third parties the fact that I am seeking insurance coverage from
RBC Life.
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to RBC Life any information,
records or other data regarding me and my medical history or treatment, or my past and present income or employment, which they
have in their possession or control.
Persons to whom this Authorization applies: Any physician, nurse, counsellor, 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; and also any federal or provincial government department or organization, including the Workers’ Compensation
Board/Workplace Safety and Insurance Board and the federal or provincial income tax authorities; and also to any other organization,
institution or person having information, records or data regarding me, my medical history or treatment or my past and present income
and employment.
I understand that any information, records or data received by RBC Life pursuant to this authorization will be used for the purpose of
determining eligibility for coverage under group insurance offered by my employer (underwriting), for the purpose of administering the
group insurance policy(ies) arranged through my employer or for the evaluation of any claim for benets.
To the extent reasonably necessary for this purpose, I authorize RBC Life to disclose any of the said information, records or data
received to other insurance companies or any reinsurer; or to my employer and its insurance brokers or advisors or its benet plan
administrators; or to any other person or rm employed or engaged by RBC Life.
If this application is being made on behalf of my dependant(s), I am authorized to disclose information about them, for the purposes of
underwriting, administration or adjudication of claims. I conrm that RBC Life is authorized to disclose information about this application
to me, for the purposes of assessing this application and managing my group benets plan.
A photocopy of this authorization, as executed by me, shall be as valid as the original and shall continue to have effect throughout the
duration of my coverage under the group coverage offered by my employer.
Signature of Employee: _________________________________________________ Date: _________________
Signature of Employee’s Spouse (if applying): _______________________________ Date: __________________
Please send the completed form using one of the following options:
Email: MedicalUnderwritingSupport@rbc.com
Mail: Please place in an envelope marked “Private and Condential” and retain a copy for your records.
RBC Life Insurance Company
Tower 1, 8th Floor, 6880 Financial Drive
Mississauga ON L5N 7Y5
Page 10 of 11
101398 (12/2019)
VPS105596
COLLECTION AND USE OF PERSONAL INFORMATION
Collecting your personal information
We (RBC Life Insurance Company) may from time to time collect information about the employer and the employees (collectively
“clients”) such as:
information establishing identity (for example, name, address, phone number, date of birth, etc.) and personal background;
information related to or arising from the relationship with and through us;
information provided through the application and claim process for any insurance products and services; and
information for the provision of products and services.
We may collect information from the employer or the employee, 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 and motor vehicle reports.
Health information will not be shared with the employer without the consent of the employee.
Using personal information
This information may be used from time to time for the following purposes:
to verify the identity and investigate the background of the employer and employee;
to issue and maintain insurance products and services that may be requested;
to evaluate insurance risk and manage claims;
to better understand the insurance situation of our clients;
to determine eligibility for RBC insurance
®
products and services;
to help us better understand the current and future needs of our clients;
to communicate to our clients any benet, feature and other information about RBC
®
products and services maintained with us;
to help us better manage our business and the relationship with our clients; 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 a client’s social insurance number, we may use it for tax related purposes and share it with the appropriate
government agencies.
Right to access of personal information
Our clients may obtain access to the information we hold about them 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, the employee 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.
Page 11 of 11
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