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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  • 8 check-boxes
  • 83 other fields

Country of origin: CANADA
File type: PDF

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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.
-
LIS OF INSURED CLAIMANTS
CLAIM AND AUTHORIZATION FORM
Last Name: Fi
rst Name: Date of Birth:
Address:
City: Province: Postal Code:
Home Phone: Mobile Phone:
Email Address:
‘You’ or ‘Your’ refers to the primary insured named on this claim form. If the Primary insured is a minor, the parent or legal
guardian is referred to as ‘You’ or ‘Your’
Please select your preferred method of contact: Email Home Phone Mobile Phone
If you selecte
d ‘Home Phone’
or ‘Mobile Phone’; please advise the best time/day to be reached between Monday – Friday
8AM – 5PM EST
Enter Time: ____________ Prefered d
ay: Monday Tuesday Wednesday Thursday Friday
(by select
ing your preferred method of contact, you are providing consent for RBC Insurance Company of Canada to discuss
your claim information via phone or email)
CANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATION
Your medical history may be required to fully review your claim. Please provide your Canadian Physician(S) information below
Family Physician(s):
Telephone:
Walk-in Clinic (if applicable):
Telephone:
Canadian Specialist(s):
Telephone:
CLAIM DETAILS
1. Trip
Departure Date: Trip Return Date: _____________________ _____________________
2. The date you sought medical attention:
_____________________
3. The reason for
seeking medical attention (diagnosis):
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
NO - Please provide name and address of whom the claim should be paid out to:
Name:
Address:
OTHER INSURANCE INFORMATION
1. Please enter your Provincial Health Insurance Plan Card Number:
Version code (Ontario Only):
Some Ontario residents have 1 or 2 Alpha letter(s) added at the end of their OHIP Card Number
CLAIMANT INFORMATION - MEDICAL
Select
2. Are you, or your spouse, entitled to benefits under any other plan for the medical expenses being claimed?
YES
NO
If YES, please provide details below; if NO, leave blank and complete the next section;
You Your spouse
Name of Insurance Company:
Plan Number:
Plan Member ID Number:
If spouse's plan, please provide spouse's name:
and date of birth:
3. Do you have a Credit
Card?
YES NO
If YES,
please
provide
details below;
To
help you r
eceive all additional 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.
Type of Credit
Card:
Credit Card
Number:
LIST OF SUBMITTED EXPENSES - MEDICAL
Currency:
-
Currency:
List eligible expenses you paid for
below: (i.e. prescriptions, Dr. visit,
meals, ambulance, etc.)
Date Incurred Amount
Currence expenses
paid in
Original Receipts
Enclosed Yes/No
* Please attach another sheet if your expenses exceed the space provided
* If your amounts are in more than one currency, please total each separately
Total Amount: ___________ __________________________
Total Amount:
___________ __
______________________________
I THE UNDERSIGNED,
empower RBC Insurance Company of Canada located at PO Box 97, Station A, Mississauga, ON, L5A 2Y9 to:
1. Submit to the Régie de l’assurance maladie du Quebec (the Régie), in accordance with the laws and regulation applied
by the Régie, my claims for insured medical services which I, my spouse or my children received (family insurance)
in (location):
during our stay from: to:
Family Insurance: For the purposes of family insurance, this power of attorney applied only to me, my spouse and my
children,
identified below:
1. Spouse
Health Insurance Number:
2. Children
Health Insurance Number:
Health Insurance Number:
POWER OF ATTORNEY - MEDICAL
-
2. Transmit to, and receive from, the Régie all information and documents required for the assessment and payment of
said claims.
3. Receive from the Régie all amounts reimbursed and due to me, my spouse or my children (family insurance).
I AUTHORIZE the Régie to accept the claims so submitted, to act in accordance with this Power of Attorney as
specified and to transmit to the company any information it may request concerning the insured person status of
myself, my spouse or my children.
Insured person’s signature
Insured person’s Health Insurance Number Policy or claim number
(This number corresponds to the one
which must appear on the Statement
of payments and reimbursements)
The following authorization statements are providing RBC Insurance Company of Canada authorization to obtain, recover
and forward information, payments and/or obtain recovery from your Provincial Health Insurance Plan , Extended Health
benefits company and/or other sources on your behalf.
1.
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.
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 hereby assign to RBC Insurance Company of Canadaany benefits obtainable from other sources for losses covered
under this policy. I also direct these sources to forward payment to RBC Insurance Company of Canada for my claim
submitted by RBC Insurance Company of Canada with regard to these losses. A photocopy or faxed copy of this
authorization is acceptable.
Print Name of Claimant/Designated Legal Representative
Date
Signature of Claimant/Designated Legal Representative
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 - MEDICAL
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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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