1-877-519-9501
Fax
416-643-4940
1-800-714-8861
____________________________________ _________________________
________________________________________________________________
________________ _______________ _Long Term Care Questionnaire
In order for us to assess your claim, kindly have your care provider answer the following
questions:
1. Is this a claim for: Facility Care Home Care
2. Name of Insured: Date care commenced:
3. Name, address and telephone number of Facility / Home Care Provider:
4. Current proof of payment made to the above Facility / Home Care provider (please
attach copies of cheques/receipts, admission statements and invoices – kindly
note that without these documents, we will be unable to assess this claim)
5. Is the Insured able to perform the following activities independently?
Walking (details/comments):
Transferring from a bed or chair (details/comments):
Dressing (details/comments):
Toileting (details/comments):
Eating (details/comments):
Taking Medications (details/comments)
6. Please describe the type of care you are providing or attach a copy of your Plan of Care:
Name and
Signature
of
Director
of
Patie
nt
Care
(if
Facility
Care)
________________________________________________
Name and
Signature
of
Home
Care Provider
(if
Home Care)
________________________________________________
RBC Life Insurance Company
Customer Care Centre
PO
Box 4435,
Station
A
Toronto ON
M5W
5Y8
416-643-4700
