Fillable Group Life / Accidental Death Notice of Claim (RBC Insurance)

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Group Life / Accidental Death Notice of Claim (RBC Insurance)

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Country of origin: CANADA
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Group Life / Accidental Death
Notice of Claim
VPS 105649 83736 (09/2019)
EMPLOYER INSTRUCTIONS
Send the Client’s Statement
to the beneciary for completion
and have it returned to you.
Complete the Employer’s Statement.
Send these documents to RBC Insurance at:
P.O. Box 4435, Station A
Toronto, ON M5W 5Y8
Tel 416-643-4700
Toll Free 1-877-519-9501
Fax 1-800-714-8861
www.rbcinsurance.com
For all Accidental Death claims:
For Life Insurance amounts up to $150,000:
For Life Insurance amounts of $150,000 or more:
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 Statement.
The original enrollment form and any change of
beneciary form(s).
If the beneciary is the Estate of the Insured, a copy of the
court appointment naming the executor, administrator or
personal representative.
Provide a completed Physician’s Statement.
Provide a copy of the funeral director’s statement
or a completed Physician’s Statement.
Provide a certied copy of the death certicate
or a completed Physician’s Statement.
____________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
________________________________________________
________________________________________________ _____________________________________________________________
Date of Birth:
If “Yes,” please describe:
GROUP LIFE / ACCIDENTAL DEATH CLAIM FORM
CLIENT’S STATEMENT
1. My name in full is: _______________________________________________________________ ________________________
(DD/MM/YYYY)
Address: Telephone No: ( )
Apt. Street City Province Postal Code
I am making a claim in the capacity of: _________________________________ under Policy No(s) _________________________________
(state whether Beneciary, Administrator, Guardian, Trustee or Assignee)
issued to _____________________________________ now deceased. Beneciary S.I.N. No.
2. What was your relationship to the deceased? _______________________ What was the deceased’s date of birth?_______________________
(DD/MM/YYYY)
3. The deceased was injured on: ___________________________________________ died on: _______________________________________
(DD/MM/YYYY) (DD/MM/YYYY)
4. Was death the result of an accident?
Yes o No o
___________________________________________
5. When and where was the deceased rst attended by a physician in relation to this claim? _________________________________________
6. List all physicians and hospitals where treatment was received over the past ve years:
Name of Physician/Hospital Address Dates Seen (DD/MM/YYYY)
7. Did the deceased have other life insurance at the time of death?
Yes o No o
If “Yes,” please provide names of companies
and amounts of insurance:
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)
, verify that the above statements are true and complete to the best of my knowledge and belief.
Date
(DD/MM/YYYY) ____________________________________ Signature of Client ________________________________________________
AUTHORIZATION
To Whom It May Concern:
I, ______________________________________, hereby authorize any hospital, physician, medical practitioner, clinic, other medical or
medically related facility, pharmacy, coroner’s ofce, police department, insurance company to disclose or furnish to the Company (the Company
refers to and includes each of RBC Life Insurance Company, RBC Insurance Services Inc., their services providers, representatives and any
participating reinsurers), any and all information with respect to any illness including AIDS, AIDS Related Complex (ARC), mental illness, drug/
alcohol abuse, injury, medical history, consultations, prescriptions, treatments or benets, and copies of all applicable records concerning
___________________________, that may be requested. I also authorize his/her employer to disclose all information needed to process the claim.
The information provided to the Company, its subsidiaries or representatives is to be used solely for the administration of claim(s)
as captioned above.
A photocopy of this authorization is to be considered as valid as the original and is effective for the duration of the claim.
Date
(DD/MM/YYYY)
Relationship of Authorized Person to Deceased Authorized Person’s Signature
VPS 105649 83736 (09/2019)
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Yes
(DD/MM/YYYY)
No
GROUP LIFE / ACCIDENTAL DEATH CLAIM FORM
EMPLOYER’S STATEMENT
1. INSURANCE INFORMATION (Complete for all claims)
Indicate the type
of claim
being led:
o
Employee Life
Dependent Life
Accidental Death
Did the deceased
have other
insurance?
Group Life Insurance
o Y e s o No o
Unknown
o
Individual Life Insurance
o Yes o No o
Unknown
o
Disability Insurance
o Yes o No o
Unknown
2. EMPLOYEE INFORMATION (Complete for all claims)
Full Name of Insured Employee Social Insurance Number Date of Birth
______________________
(DD/MM/YYYY)
Address of Employee (Apt. / Street / City / Province / Postal Code)
Occupation Salary/Rate of Pay (Attach verication of earnings) $__________________
o Full-time o Part-time o Seasonal
Amount of RBC Insurance Basic Life $ _______________________
Group Life Insurance Voluntary Life $ _______________________
Effective Date of RBC Insurance
___________________
Life Insurance
(DD/MM/YYYY)
Date of Last Change in
Amount of Insurance
________________
(DD/MM/YYYY)
Amount of
Last Change $
Basic Life $____________
o
Increase
o
Decrease
_____________
Voluntary Life $____________
o
Increase
o
Decrease
Date Employed
_________________
(DD/MM/YYYY)
Date Last Worked
_________________________
(DD/MM/YYYY)
Date of Death
__________________
(DD/MM/YYYY)
Reason for Ceasing Work Cause of Death
Are Accidental
Death benets being
claimed?
If “Yes,” give amounts
o
o No
Basic $ ________________
Voluntary $ ________________
Was a Claim for Waiver
of Premium submitted
prior to death?
o Yes
o No
Was Insured considered
a member/employee at
date of death?
o Yes
o No
Death or Disability due to:
(If Occupational, attach Employer’s Accident Report)
o
Non-Occupational accident
o
Occupational accident
Date and time
of
Accident _
a.m./p.m.
__________________
Have premiums
terminated?
o Yes
- give date
_____________________
o No
(DD/MM/YYYY)
If Insurance was terminated, was
Insured notied of conversion
right?
o Yes
- give date
_____________
o
(DD/MM/YYYY)
DEPENDENT CLAIM INFORMATION (Complete for Dependent Life &/or Dependent Accidental Death Claims only)
Full Name of Deceased Dependent Relationship to Employee Date of Birth
____________________
(DD/MM/YYYY)
Date of Death
_________________________
(DD/MM/YYYY)
Effective date of
Dependent Insurance
_________________________
(DD/MM/YYYY)
Amount of
Insurance $ ___________________
BENEFICIARY INFORMATION (Complete for all claims)
Name of Beneciary Relationship to Employee Beneciary Date of Birth
_____________________
(DD/MM/YYYY)
Address (Apt./Street/City/Province/Postal Code) Beneciary Social Insurance Number
EMPLOYER INFORMATION (Complete for all claims)
Company Name If an afliate, subsidiary, branch or employer member, give name:
Address (Street / City / Province / Postal Code) Telephone No.
To the attention of: Title
Group Policy No(s).
Division No.
Class No.
Signature
X
Date
____________________________
(DD/MM/YYYY)
VPS 105649 83736 (09/2019)
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VPS 105649 83736 (09/2019)
 
_________________________________________________________________ ____________________________ _____________________
GROUP LIFE / ACCIDENTAL DEATH CLAIM FORM
PHYSICIAN’S STATEMENT
Full Name of Deceased
Date of Death ___________________________
(DD/MM/YYYY)
Residence at Death Place of Death
Age at Death or Date of Birth
________________________________________________
(DD/MM/YYYY)
(If Hospital or Institution, Give Name)
Cause of Death (Enter only one cause for each of a, b and c).
Interval Between Onset
and Death
Disease or condition directly leading to death: (This does not mean the mode of dying, such as heart failure, asthenia,
etc. It means disease, injury or complication that caused death).
(a)
(a)
Antecedent causes: (Morbid conditions, if any, giving rise to the above cause (a) stating
the underlying cause last).
Due to (b)
(b)
Due to (c)
(c)
Other signicant conditions: (Contributing to the death but not related to the disease or condition causing death).
Date of Last Attendance in First Illness ___________________________
Date of Last Attendance in Last Illness ___________________________
(DD/MM/YYYY) (DD/MM/YYYY)
If death was due to an accident, suicide or homicide, specify which.
Describe briey.
Was an inquest held?
Was an autopsy performed?
If so, by whom and with what ndings?
o Yes
o Yes
o No
o No
Were the injuries described above, alone and independent of all other causes, sufcient to produce the death of a
normal and healthy person?
o Yes o No
Had he / she, in your opinion, been using alcohol, non-prescription drugs and / or prescription drugs other than as
prescribed?
o Yes o No
Have you treated or advised the deceased during the last 3 years, prior to the last illness?
o Yes o No
Did the deceased, to your knowledge, receive treatment during the last 3 years from any other physician, or in any
hospital or institution?
o Yes o No
If “Yes” to either question, please provide the following:
Name Address Nature of Illness or Injury Dates (DD/MM/YYYY)
Any charge for the completion of the form is the responsibility of the Client.
X
Signature Date
(DD/MM/YYYY)
Degree and Specialty
Physician’s Name
________________________________________________________________________
o
Primary Care
o
Consultant
Address
__________________________________________________________________________________________
o
Other ___________________
(Street / City / Province / Postal Code)
Telephone No.: (_______)_____________________________________ Fax No.: (_______)________________________________________
MAIL YOUR COMPLETED FORM TO:
RBC LIFE INSURANCE COMPANY, LIFE AND HEALTH CLAIMS DEPARTMENT
P.O. Box 4435, Station A, Toronto, ON M5W 5Y8 or fax to: 1-800-714-8861
If you have any questions, call toll free 1-877-519-9501 OR 416-643-4700
www.rbcinsurance.com
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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VPS 105649 83736 (09/2019)
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 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.
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Group Life Accidental Death Notice of Claim (RBC Insurance)

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Completed 21 May 2021

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