Print Name of Claimant/Designated Legal Representative
NO - Please provide name and address of whom the claim should be paid out to:
NO
Signature of Claimant/Designated Legal Representative
4. If you incurred eligible expenses and your claim is payable, should the cheque be made out in your name?
YES - The Claim will be paid out to me
Name:
Address:
5. Was the trip purchased with a Credit Card?
YES
If YES, please provide details below;
To help you
receive all addit
ional
payments
you are entitled to,
we will coordinate with any other potential Insurers on
your
behalf.
We will determine if the card provides coverage for
your
incident.
Credit Card
Number:
Type of Credit
Card:
The following
authorization wording is providing RBC Insurance Company of Canada authorization to obtain, recover and
forward information, payments and/or obtain recovery from your Credit Card, Extended Health benefits company, Airlines
and/or other sources on your behalf.
1. I
hereby assign, to RBC Insurance Company of Canada, any claim or right
of action I may
have against
any person,
company
or organization for the loss or expense that has been paid to me by RBC Insurance Company of Canada. This
assignment includes
but
is
not
limited to any rights I may
have for any full or partial refund, credit or other benefit that
may
be available to me from any
person, company
or organization including but not limited to any airline, travel provider,
tour
operator, travel company and/or credit card company.
I further agree to cooperate with RBC Insurance Company of
Canada
in its efforts to enforce my rights as
against
any
other party
and agree that RBC
Insurance Company
of Canada
may, in relation to the rights I am assigning to them, commence a legal action in my
name as against any
other party at its
own expense.
If I recover
against any third party, I
agree to hold in trust sufficient
funds to reimburse RBC Insurance
Company of Canada
for the amount of the loss or expense it paid to me.
I hereby
direct that any
payment from any
person,
company
or organization in relation to any claim,
right of action, refund, credit or other benefit
which I have hereby
assigned, shall
be made payable to RBC Insurance Company
of Canada.
A copy
of this assignment and direction shall
have the same authority
as the original.
2. I understand my claim may be subject to review and investigation and I give RBC Insurance Company of Canada or their
authorized agents authority to acquire any documents or statements from other insurers, financial institutions, travel
suppliers, any company or public/private organization which can provide information related to my claim, and I hereby
consent to the disclosure of such information by RBC Insurance Company of Canada to other sources as may be required
for the processing of my claim.
3. I authorize you to give RBC Insurance Company of Canada any and all information you have regarding me, while under
observation or treatment by you, including my medical history, diagnoses and test results, and I hereby consent to the
disclosure of such information by RBC Insurance Company of Canada to other sources as may be required for the
processing of my claim for benefits obtainable from other sources.
Date
If claimant is a minor the Parent or Legal Guardian must sign this section on his/her behalf. If a legal representative,
other than the patient’s legal guardian signs this form, proof of “Legal Representative status” is required i.e. (Power of
Attorney, Will, etc.). A copy of this authorization shall have the same authority as the original.
AUTHORIZATION - TRIP CANCELLATION - NON MEDICAL
click to sign
signature
click to edit
![]()
