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VPS 107828
Email address :
Name of Doctor First Consulted Address
 
Notice of Critical Illness
Claim Form
Are you ling a claim for Critical Illness or for Return of Premium on Death?
Critical Illness:
complete all sections below
Return of Premium on Death:
complete sections A, F and G below; and
attach a Funeral Directors Statement
Mr. Mrs. Ms. Other Male Female Policy No(s):
Claim No(s):
Telephone No. (H):
Date of Birth:
Postal Code
1. a) Please describe the type of Critical Illness (or surgery):
Date your condition was diagnosed and/or surgery performed:
Name of physician who made the diagnosis:
Please describe the symptoms and indicate when the symptoms rst started:
e) On what date did you rst consult a medical practitioner in connection with your illness/injury?
f) Have you undergone any tests or investigations related to the diagnosis?
Yes No If “Yes”, please provide dates and details:
g) Have you previously suffered from, or received treatment for, a similar or related condition?
Yes No
If “Yes”, please provide dates and details:
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VPS 107828
Name of Physician Address Dates Seen
Admission Date
Discharge Date
Name of Hospital/Institution City/Town
Type of Treatment Institution/Prescribing Physician Dates (
Relationship Nature of Illness Age when illness First Diagnosed
2. a) Please provide the name and address of your personal physician:
b) Please provide details of any other physicians or specialists who have been consulted in connection with your illness/injury:
c) If you have been treated, examined or tested at a hospital or similar institution, please provide the following information:
d) What treatment have you received and are currently receiving in connection with your condition? (i.e. medications, therapy, etc.)
Has any blood relative suffered from a similar or related condition?3. Yes No If “Yes”, please indicate:
4. Are you insured for benets related to this condition from another company? Yes No If “Yes”, please indicate:
Name of Insurer Type of Benet
Amount of Benet
Has a Claim been submitted?
5. Do you smoke or use tobacco products? Yes No
If “Yes”, indicate amount per day: How long have you used tobacco products?
6. Please provide any further information that you think might be relevant to your claim.
Transit No.: Institution No.: Bank Account No.:
Account: Chequing Savings (Credit Line Accounts not accepted)
I authorize RBC Life Insurance Company (“RBC Insurance”) to deposit my benet payments to the bank account and nancial
institution indicated above, until further written notice from me.
Signature: Date:
*Attach an unsigned digital copy of a cheque marked “VOID”.
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Any person who knowingly files a claim form containing false or misleading information is subject to criminal
and civil penalties.
I, , declare that the above statements are true and
complete to the best of my knowledge and belief.
(print name)
Date Signature of Client
I understand and authorize the Company (the Company refers to and includes each of RBC Life Insurance Company, RBC Insurance Services Inc., and their
service providers, representatives and their reinsurers) to conduct such investigation as is necessary, to gather personal information concerning me from
third party sources, including the collection of any personal information that is available online, including, without limitation, news websites, social media,
professional or business directories and public registries, and to disclose as necessary to third parties that I am making a claim to the Company for benets
and relevant information concerning that claim. I understand that the Company will create and maintain les, which contain personal information concerning
me. I also understand that access to personal information concerning me will be limited to, the employees of, and other persons engaged by, the Company, in
the performance of their duties, or the persons to whom I have granted access, in writing, or to any other person or organization authorized by law. I have read,
understand and agree with the Global Privacy Notice published at https://www.rbc.com/privacysecurity/ca/global-privacy-notice.html.
I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me, I will be permitted to review
copies of documents containing said personal information in the possession of the Company, upon paying reasonable copying charges. I further understand
that I will be permitted to request access to such documentation and have any errors in the personal information noted and corrected by formulating a written
request to the Company mailed to the employee who is handling my claim.
I acknowledge and agree that if I choose to use, or instruct the Company to use, any electronic communication that is not encrypted, including without
limitation, any fax or email communication, that (i) security, privacy and condentiality cannot be ensured, (ii) such communication is not reliable and may not
be received by the intended recipient in a timely manner or at all, (iii) such communication could be subject to interception, loss or alteration, and (iv) I assume
full responsibility for the risks in connection with such communication and the Company will not be responsible or liable in any way in connection with such
communication, including without limitation, any unauthorized access to or interception, loss or alteration of such communication.
Your Authorization to Disclose Personal Information
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information, records or other data
regarding me, my medical history or treatment, or my past and present income, employment, education or training, 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 or workers’ compensation; and also any federal or provincial
government department or organization, including the Workers’ Compensation Board/Workplace Safety and Insurance Board, the CPP/QPP disability/retirement
authorities, and the federal or provincial income tax authorities; and also to any other person, agency, credit bureau or institution having information, records or
data regarding me, my medical history or treatment, or my past and present income, employment, education or training.
I understand that any information, records or data received by the Company pursuant to this authorization, both medical and non-medical, will be used for
the purpose of determining coverage under the policy, evaluating my claim for benets, my ability to return to work and/or for the purpose of assisting with
the co-ordination of my return to work, for the purpose of administering the group and/or individual plans of insurance (including life, accidental death and
dismemberment and disability policies of insurance) arranged through my employer with the Company or another insurer, for the purpose of providing ongoing
claim status information to my employer at the time the claim was incurred, for the recovery of any overpayment of benets incurred by me, if necessary, or
for the purposes of fullling its (or RBC Financial Group’s) obligations or investigations with respect to audits, anti-money laundering, terrorist nancing, fraud
detection, prevention or suppression or other criminal activities. To the extent reasonably necessary for those purposes, I authorize the Company to disclose
any of the said information, records or data received: to other insurance companies or any reinsurer; or to my employer and their insurance brokers or advisors
or their benet plan administrators; or to my physicians or health care providers; or to any other person or organization (including physicians, health care
practitioners, rehabilitation workers, vocational evaluators) employed or engaged by the Company.
I also authorize the Company to collect, use and disclose, as necessary and relevant, my personal information from any prior claim(s) and/or for any subsequent
This authorization does not have any expiry date. It will remain valid for as long as I am claiming eligibility for benets or services from the Company and while
the Company pursues subrogation rights or the recovery of any overpayment of benets incurred by me, if necessary, whether or not benets are being paid,
and whether or not either party takes the position that there has been a breach of contract. A photocopy of this authorization, as executed by me, will be as
valid as the original.
X Date:
Signature of Client (DD/MM/YYYY)
Name of Client (Please Print)
Signature of Witness
Name of Witness (Please Print)
Send the completed form and documents to our ofce by email: intake@rbc.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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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
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 also collect information from third
party resources, including the collection of any personal information that is available online, including, without limitation,
news websites, social media, professional or business directories and public registries, and resources. 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
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.