DT AGT
RBC Policy Number Billing Division Number(s)
Policyholder Name
Policyholder Address
City Province Postal Code
Telephone Number Fax Number
To ensure accuracy, attach a void
cheque to the upper right corner.
Name of Bank or Financial Institution
Province Postal Code
PAD withdrawals are on
the eighth of each month. Bank Number
Transit Number Account Number
The Payer (Policyholder) named above agrees that:
1. a) RBC Life Insurance Company (RBC Life) is authorized to withdraw monthly recurring premium payments from the bank account for the policy
referred to herein and to exchange relevant nancial information with the Payer’s nancial institution above, or any other nancial institution that the
Payer may later designate. Withdrawals shall be on the eighth of each month.
b) RBCLifeisnotrequiredtoprovidepre-noticationoftheamountofthePADandisnotrequiredtoprovideadvancenoticeofthePADs
c) the nancial institution indicated above is authorized now or at any subsequent time to honour any requests made by RBC Life to withdraw premiums
from the account indicated above, which may include a redraw within 30 days should any withdrawal not clear the account.
d) this agreement will remain in eect until RBC Life has received written notication from the Payer of its changes or termination. This notication must
be received at least 10 business days before the next debit is scheduled at the address provided below. The Payer may obtain further information
on their right to cancel a PAD agreement by visiting the Payments Canada at payments.ca.
e) in the event that a PAD is disputed, the Payer agrees to contact RBC Life at 1-855-257-1598. The Payer has certain recourse rights if any debits do
not comply with this agreement. For example, the Payer has the right to receive reimbursement for any PAD that is not authorized or is not consistent
with this PAD agreement. To obtain more information on recourse rights, the Payer may contact their nancial institution or visit payments.ca.
f) the names and signatures of all persons required to authorize withdrawals from the account indicated are included below .
Dated at this day of
(City/Province) (Month/Year)
Print Name of Payer (Account Holder) Print Name of Second Payer (Account Holder) (if any)
Signature of Payer Signature of Second Payer (if any)
Please email completed form to admin@groupinsurance.rbc.com
RBC Life Insurance Company, PO Box 1600, 8677 Anchor Drive, Windsor, Ontario N9A 0B3 www.rbcinsurance.com
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
VPS 106313
122684 (12/2019)
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