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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The Please find attached the Claim and Authorization form, (RBC Insurance) form is 4 pages long and contains:

  • 1 signature
  • 8 check-boxes
  • 109 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.
- -
CANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATIONCANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATIONCANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATION
CLAIM AND AUTHORIZATION FORM
Last Name: F
irst Name: Date of Birth:
Address:
City: Province: Postal Code:
Home 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 selected ‘Home Phone’ or ‘Mobile Phone’; please advise
the best time/day to be reached between Monday – Friday
8AM – 5PM EST
Enter Time: ____________ Prefered day: Monday Tuesday Wednesday Thursday Friday
(by selecting your preferred method of contact, you are
providing consent for RBC Insurance Company of Canada to discuss
your claim information via phone or email)
LIST OF INSURED CLAIMANTS
Full Name
Date of Birth (mm-dd-
yy)
Relationship to
Insured
If a dependent child, is he/she a full time
student?
CANADIAN FAMILY DOCTOR AND/OR SPECIALIST INFORMATION
Your medical history may be required to fully review your claim. Please provide your Canadian Phyisician(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. Date you had reason to interrupt or change your trip: _____________________
3.What symptoms did you have or what was the diagnoses given by the attending doctor?
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:
Mobile Phone:
CLAIMANT INFORMATION - TRIP INTERRUPTION- MEDICAL
Select
Full Name
Date of Birth (mm-dd-
yyyy)
Relationship to
Insured
If a dependent child, is he/she a full time
student?
LIST OF INSURED CLAIMANTS
- -
5. Was the trip purchased with a Credit Card? YES NO
If YES, please provide details below;
To help you receive 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.
Credit Card
Number:
Type of Credit
Card:
Description
Original Amount
Paid
Amount of Refund/
Voucher/Credit
Offered to You
Offered By
Remaining
(Amount Claimed)
* If your amounts are in more than one currency, please total each separately
Total Amount: ___________ Currency: __________________________
Total Amount: ___________ Currency: __
______________________________
REFUND/VOUCHER/CREDIT INFORMATION
LIST OUT-OF-POCKET EXPENSES
Description of your Out-of-Pocket Expenses
Date Incurred
Amount
Currency
Expenses Paid in
Original Receipts
Enclosed Y/N
* If your amounts are in more than one currency, please total each separately
Total Amount: ___________ Currency: __________________________
Total Amount: ___________ Currency: __
______________________________
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.
AUTHORIZATION - TRIP INTERRUPTION - MEDICAL
- -
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.
Print Name of Claimant/Designated Legal Representative
Signature of Claimant/Designated Legal Representative
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 INTERRUPTION - 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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