Fillable NOTICE OF HOME CARE CLAIMANTS STATEMENT (please print) (RBC Insurance)

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NOTICE OF HOME CARE CLAIMANTS STATEMENT (please print) (RBC Insurance)

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The NOTICE OF HOME CARE CLAIMANTS STATEMENT (please print) (RBC Insurance) form is 2 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 31 other fields

Country of origin: CANADA
File type: PDF

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____________________________________________ taking medications as prescribed ?
Date Home Care Commenced
Weekly/Monthly
Amount of Benefit
Name of Company
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________ _________________ _____________________
____________________________________________ _________________ _____________________
____________________________________________ _________________ _____________________
RBC Life Insurance Company
4435 Stn A
Toronto, ON M5W 5Y8
NOTICE OF HOME CARE
CLAIMANT’S STATEMENT (please print)
Full Name _______________________________________________________________________________________
Date of Birth _________________________________________ Policy Number _______________________________
Home Address ___________________________________________________________________________________
Telephone Number ________________________________________
Diagnosis _______________________________________________________________________________________
Date of Diagnosis _________________________________________________________________________________
Do you currently need another person’s help in performing any activities of daily living, such as
bathing dressing toileting eating walking indoors transferring from bed to chair controlling
bladder or bowel functions
Name of Home Care Provider _________________________________________________________________________
________________________________________________________________________
Telephone Number _________________________________________________________________________________
Describe the
services required ________________________________________________________________________
Outline the cost and frequency of required care ___________________________________________________________
Source and amount of applicable provincial
benefits ________________________________________________________
Do you own Long Term Care coverages of any kind with any other Insurance Company? Yes
No If yes,
complete below:
Waiting Period
for benefits
™Trade-marks of Royal Bank of Canada. RBC Life Insurance Company, licensee of trade-marks.
_____________________ ______________________________________________ ________________________
SIGNATURE OF CLAIMANT
I authorize any health care professional, health or social service establishment, insurance company, the Medical
Information Bureau, financial institution, personal information agents or security agencies, my current employer or
any former employer and public body holding personal information concerning me, particularly medical information, to
supply this information to RBC Life Insurance Company and its reinsurers. Such information will be provided for
investigations necessary to adjudicate my claim or assess the validity of the policy as issued.
I understand that if I refuse to provide this information, RBC Life Insurance Company will be unable to adjudicate my
claim or assess the validity of the policy as issued.
A photocopy of the signed authorization to obtain this information will be as legally valid as the original.
This authorization will be valid until revoked by written notice to RBC Life Insurance Company.
DATE SOCIAL INSURANCE NUMBER
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NOTICE OF HOME CARE CLAIMANTS STATEMENT (please print) (RBC Insurance)

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Completed 21 May 2021

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