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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
Description of your Out-of-Pocket Expenses
Date Incurred
Amount
Currency
Expenses Paid in
* If your amounts are in more than one currency, please total each separately
Total Amount: ___________ Currency: __________________________
Total Amount: ___________ Currency: __
______________________________
LIST OUT-OF-POCKET EXPENSES
Original Receipts
Enclosed Y/N
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.
AUTHORIZATION - TRIP INTERRUPTION - NON MEDICAL