Fillable Pre-Authorized Debit Agreement Policy Number Name of (Proposed)

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Pre-Authorized Debit Agreement Policy Number Name of (Proposed)

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00652 & (06/2020)
Pre-Authorized Debit
Agreement
For the purposes of paying premiums under the following:
Policy Number Name of (Proposed) Insured
Pre-Authorized Debit (PAD) Agreement:
Ensure you read and understand the section “Collection and Use of Personal Information”.
The Payor(s) named below agrees that:
1 (a) RBC Life Insurance Company (RBC Life) is authorized to make scheduled monthly withdrawals to pay the
premium in accordance with the premium schedule set out in this policy/policies, including the initial premium
against the account at the nancial institution below, or any other nancial institution that the Payor(s) may later
designate;
(b) RBCLifeisnotrequiredtoprovidenoticationbeforetheinitialpremiumisdebited,oriftheamountofthe
withdrawal should vary;
(c) unless otherwise indicated in the Special Requests section below, such withdrawals shall be dated on the day of
the month on which the premium is due under the policy or, if more than one policy is included in this Agreement,
the withdrawals shall be dated to coincide with the existing policy/policies;
(d) the nancial institution indicated below is authorized now or at any subsequent time to honour any requests made
by RBC Life to withdraw the premium or fees from the account indicated below, which may include a redraw within
30 days should any withdrawal not clear the account;
(e) notication of any change to the account information provided below shall be given to RBC Life by the Payor(s) a
minimum of 5 days prior to the next scheduled withdrawal. The Payor(s) agrees that from time to time they may
authorize RBC Life to deduct such payments from another account upon the Payor’s oral or written instructions;
(f) this Agreement will terminate in respect of all policies included in it upon 10 days written notice by RBC Life or by
the Payor(s). The Payor(s) may obtain further information on their right to cancel a PAD agreement by visiting the
Payments Canada website at www.payments.ca;
(g) in the event that a PAD is disputed, the Payor(s) agrees to contact RBC Life. For recourse purposes, this PAD is
considered a Personal PAD.
The Payor(s) has certain recourse rights if any debits do not comply with this agreement. For example, the
Payor(s) has the right to receive reimbursement for any PAD that is not authorized or is not consistent with this
PAD Agreement. To obtain more information on recourse rights, the Payor(s) may contact their nancial institution
or visit www.payments.ca;
(h) the names and signatures of all persons required to authorize withdrawals from the account indicated are
included below.
2 Add to the existing PAD with policy number(s):
3 Special Requests (withdrawals are limited between the 1
st
– 28
th
of the month)
Page 1 of 4
00652 & (06/2020)
Transit No. Institution No. Bank Account No.
001 00000 000 000 000 0
Bank Information:
Pleasecompletetheformbelowand,ifavailable,attachapictureofachequemarked“void”.Alineofcredit
accountcannotbeused.
Please refer to the cheque example below for assistance in completing the form.
YOUR FINANCIAL INSTITUTION
404 MAIN STREET
YOUR TOWN, PROVINCE M2M 1A7
YOUR NAME
123 ANY STREET
YOUR TOWN, PROVINCE M2M 1A7
100 DOLLARS
$
/
MEMO MP
DATE
PAY TO THE
ORDER OF
001 00000 000 000 000 0
Name of Bank or Financial Institution Transit Number Bank Number Account Number
Address
City Province Postal Code
Dated at: this day of
(City/Province) (Month/Year)
Print Name of Payor (Account Holder) Print Name of Second Payor (Account Holder) (if any)
Signature of Payor Signature of Second Payor (if any)
ATTACH A SAMPLE (VOID) CHEQUE HERE (if available)
Click the grey area below, then click “Browse”. Locate the picture of your cheque and click “OK”.
Page 2 of 4
Sample
VOID
Cheque
click to sign
signature
click to edit
click to sign
signature
click to edit
00652 & (06/2020)
COLLECTION AND USE OF PERSONAL INFORMATION
Collecting your personal information
We (RBC Life Insurance Company) may from time to time collect information about you such as:
● information establishing your identity (for example, name, address, phone number, date of birth, etc.) and your
personal background;
● information related to or arising from your relationship with and through us;
● information you provide through the application and claim process for any of our insurance products and services; and
● information for the provision of products and services.
We may collect information from you, either directly or through representatives. We may collect and conrm this
information during the course of our relationship. We may also obtain this information from a variety of sources including
hospitals, doctors and other health care providers, the MIB, Inc., the government (including government health insurance
plans) and other governmental agencies, other insurance companies, nancial institutions, motor vehicle reports, and
your employer.
Using your personal information
This information may be used from time to time for the following purposes:
● to verify your identity and investigate your personal background;
● to issue and maintain insurance products and services you may request;
● to evaluate insurance risk and manage claims;
● to better understand your insurance situation;
● to determine your eligibility for insurance products and services we offer;
● to help us better understand the current and future needs of our clients;
● to communicate to you any benet, feature and other information about products and services you have with us;
● to help us better manage our business and your relationship with us; and
● as required or permitted by law.
For these purposes, we may make this information available to our employees, our agents and service providers, and third
parties, who are required to maintain the condentiality of this information.
In the event our service provider is located outside of Canada, the service provider is bound by, and the information may be
disclosed in accordance with, the laws of the jurisdiction in which the service provider is located. Third parties may include
other insurance companies, the MIB, Inc. and nancial institutions.
We may also use this information and share it with RBC
®
companies (i) to manage our risks and operations and those of
RBC companies, (ii) to comply with valid requests for information about you from regulators, government agencies, public
bodies or other entities who have a right to issue such requests, and (iii) to let RBC companies know your choices under
“Other uses of your personal information” for the sole purpose of honouring your choices.
Ifwehaveyoursocialinsurancenumber,wemayuseitfortaxrelatedpurposesandshareitwiththeappropriate
governmentagencies.
Page 3 of 4
00652 & (06/2020)
Please note that this paragraph is not applicable if this form is submitted by an independent representative or a
representative that is attached to a rm other than RBC Insurance
®
.
Other uses of your personal information
● We may use this information to promote our products and services, and promote products and services of third parties
we select, which may be of interest to you. We may communicate with you through various channels, including
telephone, computer or mail, using the contact information you have provided.
● We may also, where not prohibited by law, share this information with RBC companies for the purpose of referring you
to them or promoting to you products and services which may be of interest to you. We and RBC companies may
communicate with you through various channels, including telephone, computer or mail, using the contact information
you have provided. You acknowledge that as a result of such sharing they may advise us of those products or
services provided.
● If you also deal with RBC companies, we may, where not prohibited by law, consolidate this information with information
they have about you to allow us and any of them to manage your relationship with RBC companies and our business.
You understand that we and RBC companies are separate, afliated corporations. RBC companies include our afliates
which are engaged in the business of providing any one or more of the following services to the public: deposits, loans
and other personal nancial services; credit, charge and payment card services; trust and custodial services; securities
and brokerage services; and insurance services.
Youmaychoosenottohavethisinformationsharedorusedforanyofthese“Otheruses”bycontactingusas
setoutbelow,andinthisevent,youwillnotberefusedinsuranceproductsorservicesjustforthatreason.We
willneveruseorshareyourhealthinformationforthesepurposes.Wewillrespectyourchoicesand,as
mentionedabove,wemayshareyourchoiceswithRBCcompaniesforthesolepurposeofhonouringyour
choicesregarding“
Other uses of your personal information
”.
Your right to access your personal information
You may obtain access to the information we hold about you at any time and review its content and accuracy, and have it
amended as appropriate; however, access may be restricted as permitted or required by law. To request access to such
information, to ask questions about our privacy policies or to request that the information not be used for any or all of the
purposes outlined in “Other uses of your personal information” you may do so now or at any time in the future by
contacting us at:
RBC Life Insurance Company
P.O.Box515,StationA,
Mississauga,Ontario
L5A4M3
Telephone:1-800-663-0417
Facsimile:(905)813-4816
Our privacy policies
You may obtain more information about our privacy policies by asking for a copy of our “Financial fraud prevention
and privacy protection” brochure by calling us at the toll free number shown above or by visiting our web site at
www.rbc.com/privacysecurity.
® / ™ Registered trademark(s) of Royal Bank of Canada. Used under licence. VPS107225
Page 4 of 4
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Completed 20 May 2021

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