Fillable Please find attached the Claim and Authorization form, (RBC Insurance)

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Please find attached the Claim and Authorization form, (RBC Insurance)

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Country of origin: CANADA
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__________________________
Please find attached the Claim and Authorization form, which is required for the adjudication of your
RBC Insurance claim.
It should be completed and submitted with all the applicable forms as listed on the online claim
submission page at the following link: http://www.rbcinsurance.com/claim.
You can complete this document digitally and include your electronic signature, then save the
document and submit along with the other required documents through the submission page above.
All
the fields with a red outline are mandatory for the processing of your claim.
Alternatively, you can print
the document and complete it. If you chose to print the document, it will need to be scanned and saved
as a digital copy on your device to attach to your document submission to begin the claim process.
When you sign this document electronically or when you sign, scan and transmit this document
electronically we will treat it as an originally signed document, and it will have the same legal effect as
if you had signed it with an original signature.
Once completed the form is considered confidential as it
contains your personal information, and it is recommended that you protect the data on your device
before and after transmission to our claims department. Your data will be encrypted when it is attached
and sent to RBC through our site at the link above in order to ensure your data is protected throughout
the submission process.
Should you have any questions, or if you prefer to receive a copy of the claim form by Email, please
contact our Claims Customer Service toll free at 1-800-387-2487 or direct at 905-816-2561. We do
accept collect calls as well should you be reaching us outside of North America.
RBC Insurance Company of Canada
P.O. Box 97
Station A
Mississauga, ON L5A 2Y9
Telephone: (905) 816-2561
1-800-387-2487
Fax: 905-813-4701
1-888-298-6320
www.rbcinsurance.com
Please note that there is a limitation period for beginning an action or proceeding against an insurer for the recovery of
insurance money payable under the insurance contract. The limitation period is set out in the Insurance Act, or The Limitations
Act, or other applicable legislation in the province in which you reside. If your contract contains a longer limitation period than the
limitation period set out in the legislation in your province, then the longer limitation period will apply.
Underwritten by RBC Insurance Company of Canada. In Quebec, Purchase Security & Extended Warranty, Emergency
Purchases, Hotel/Motel Burglary and Lost/Stolen/Delayed Baggage coverages are underwritten by Aviva General Insurance
Company.
RBC Insurance means RBC Insurance Holdings Inc., and its affiliates, which include: RBC Life Insurance Company, RBC
Insurance Company of Canada, Assured Assistance Inc., RBC Insurance Services Inc., RBC Insurance Agency Ltd., Royal
Bank of Canada Insurance Company Ltd., and RBC Insurance Company (Cayman) Limited.
-
Business Insurance Tenant Insurance
Completion of this form does not guarantee payment. Claims are subject to the terms of the policy. An incomplete form or missing
documentation may result in the delay of claim processing.
CLAIM AND AUTHORIZATION FORM
Date
Last Name: F
irst Name: Date of Birth:
Address:
City: Province: Postal Code:
Home Phone: Mobile Phone:
Email Address:
CLAIM DETAILS
Describe in detail how the loss/damage/theft occurred:
Date of incident:
Items being claimed
Purchase Date
Purchase Price (incl.Tax)
* If you have any additional items to claim, please submit on a separate sheet.
Total Amount: Currency: ___________ __________________________
PURCHASE SECURITY INFORMATION
If loss resulted from theft, was the theft reported to the Police? Yes No
If yes, provide: Copy of the Police report file number:
Police department name:
*Which if any apply to you?
Homeowners Insurance
Name: Policy Number: Deductible:
*Purchase Security protection is secondary to any other insurance, such as Homeowners, Tenant, or Business
insurance. If a Cardholder has such insurance, then the maximum amount covered under Purchase Security will be
the amount of any applicable deductible. Cardholders with other insurance have a choice in reporting a claim to that
insurance company; however, it is important to note that regardless of the decision to submit a claim or not, the
amount paid under Purchase Security will be subject to the amount stated above.
DECLARATION AND SPECIAL AUTHORIZATION
I warrant that the information provided on this form is full, complete and true. I acknowledge that the insurer may not be
obliged to make any payment if I have misrepresented any material fact.
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, 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.
A copy of this authorization shall have the same authority as the original.
Print Name of Claimant/Designated Legal Representative
Signature of Claimant/Designated Legal Representative
CLAIMANT INFORMATION - PURCHASE SECURITY
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Please find attached the Claim and Authorization form, (RBC Insurance)

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Completed 21 May 2021

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