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.
-
CLAIM AND AUTHORIZATION FORM
Currency:
Last
Name: First Name: Date of Birth:
Address:
City: Province: Postal Code:
Home Phone: Mobile Phone:
Email Address:
CLAIM AND TRIP INFORMATION
Departure Date: Return Date:
Date of the cause of interruption:
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:
LIST OF EXPENSES
Detailed Description of
your Emergency Purchases
Name of Store or
Business
Address of Store Date Purchased Amount
* 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: ___________ Currency: __________________________
Total Amount: ___________ __
______________________________
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:
CLAIMANT INFORMATION - FLIGHT DELAY
Select
Signature of Claimant/Designated Legal Representative
Do you have benefits available through any other Travel Insurance Company or Travel Supplier?
AUTHORIZATION
OTHER INURANCE INFORMATION - FLIGHT DELAY
YES NO
If yes, Policy Number:
Name & Address of Insurance Company:
I hereby warrant that I do not have any other travel insurance coverage
Claimant’s Initials: Date:
1. I hereby assign to RBC Insurance Company of Canada any 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.
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 consent the disclosure of my claim information to the following people listed: (please specify relationship)
Name: Relationship:
Name: Relationship:
Print Name of Claimant/Designated Legal Representative
Date
RESET
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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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