Fillable Individual Customer Service Request PO Box 1800 Stn (RBC Insurance)

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Individual Customer Service Request PO Box 1800 Stn (RBC Insurance)

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VPS 107283 Page 1 of 2
83512 (07/2020)
RBC Life Insurance Company is requested and authorized to make the changes below:
Policy No. Policyowner Insured
A. NAME CHANGE:
Change Policyowner’s name to
Change Insured’s name to
Reason for change: Marriage (state date) Divorce (state date) Error (explain) Court Order (explain & attach certified copies of legal documents)
Signature of Policyowner Date (DD / MM / YYYY)
All persons completing this form have attained the age of majority. Before returning, please check that the appropriate section is fully
completed, the signatures witnessed and the date of completion inserted.
RECORDED at the office of RBC Life Insurance Company
on by
B. ADDRESS CHANGE:
Change address of Policyowner Insured to:
No. and Street City or Town Province Postal Code
C. DECLARATION OF LOSS OF POLICY:
I certify that the above policy has been lost and request the issuance of:
A duplicate policy where available (required fee must accompany this request).
Do not issue a duplicate, this policy is to be terminated.
To the best of my knowledge this policy is not assigned
Signature of Policyowner Date (DD / MM / YYYY))
Individual Customer
Service Request
PO Box 1800 Stn B, Mississauga ON L4Y 3W6 • 1.888.604.3434
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VPS 107283 Page 2 of 2
83512 (07/2020)
D. COLLATERAL ASSIGNMENT OF POLICY TO: (used for collateral security)
Name:
Address:
No. and Street City or Town Province Postal Code
I/We transfer and assign all my/our right and interest to all benefit derived from the above policy to the extend of the interest of such
assignee as it may appear, subject to the terms, provisions and conditions of the policy.
Signature of Policyowner Date (DD / MM / YYYY)
E. RELEASE OF COLLATERAL ASSIGNMENT:
The consideration for the assignment of the above policy is fully paid or satisfied. I/We release all my/our right, title and interest in
the above policy.
Signature of Collateral Assignee Signature of Present Policyowner Date (DD / MM / YYYY)
F. CANCELLATION OF POLICY:
I request that my policy(ies) be cancelled effective:
a) as of the current paid to date, or
b) a future date - please specify month and year only
Signature of Policyowner Date (DD / MM / YYYY)
All persons completing this form have attained the age of majority. Before returning, please check that the appropriate section is fully
completed, the signatures witnessed and the date of completion inserted.
RECORDED at the office of RBC Life Insurance Company
on by
®
/ ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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Individual Customer Service Request PO Box 1800 Stn (RBC Insurance)

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Completed 21 May 2021

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