Fill - Free fillable Notice of Critical Illness Claim Form (RBC Insurance) PDF form

83672 (10/2020)

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VPS 107828

Email address :



  

Name of Doctor First Consulted Address

Telephone

            

  

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 Director’s Statement

A. CLIENT’S STATEMENT

Mr. Mrs. Ms. Other Male Female Policy No(s):

Claim No(s):

Name:

Last

Address:

Apt.

Telephone No. (H):

Street

First

City

Middle

Date of Birth:

Provice

(DD/MM/YYYY)

Postal Code

B. INFORMATION ABOUT YOUR CLAIM

1. a) Please describe the type of Critical Illness (or surgery):

d)

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:

(DD/MM/YYYY)

e) On what date did you rst consult a medical practitioner in connection with your illness/injury?

(DD/MM/YYYY)

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

(DD/MM/YYYY)

Admission Date

(DD/MM/YYYY)

Discharge Date

(DD/MM/YYYY)

Name of Hospital/Institution City/Town

Type of Treatment Institution/Prescribing Physician Dates (

DD/MM/YYYY)



Relationship Nature of Illness Age when illness First Diagnosed







 

C. MEDICAL CONSULTATIONS

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.)

D. GENERAL

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?



“No”,



did



you



previously



use



tobacco



products?



Yes





what



date



did



you



quit?



(DD/MM/YYYY)



6. Please provide any further information that you think might be relevant to your claim.

E. DIRECT DEPOSIT

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”.

click to sign

signature

click to edit

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F. FRAUD NOTICE

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

(DD/MM/YYYY)

G. AUTHORIZATION

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

claim(s).

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

Date:

(DD/MM/YYYY)

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

www.rbcinsurance.com

® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.

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                

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 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

www.rbc.com/privacysecurity.

® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.

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