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Any person who knowingly files a Client’s Supplementary Statement containing false or misleading information is subject to
criminal and civil penalties.
I, , declare that the above statements are true and complete to the
best of my knowledge and belief.
Signature of Client Date (DD/MM/YYYY)
I understand and authorize the Company (the Company refers to and includes each of RBC Life Insurance Company, RBC Insurance Services Inc., and their service providers, representatives
and their reinsurers) to conduct such investigation as is necessary, to gather personal information concerning me from third party sources, including the collection of any personal information
that is available online, including, without limitation, news websites, social media, professional or business directories and public registries, and to disclose as necessary to third parties that I
am making a claim to the Company for benefits and relevant information concerning that claim. I understand that the Company will create and maintain files, which contain personal information
concerning me. I also understand that access to personal information concerning me will be limited to, the employees of, and other persons engaged by, the Company, in the performance of
their duties, or the persons to whom I have granted access, in writing, or to any other person or organization authorized by law. I have read, understand and agree with the Global Privacy Notice
published at https://www.rbc.com/privacysecurity/ca/global-privacy-notice.html.
I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me, I will be permitted to review copies of documents containing
said personal information in the possession of the Company, upon paying reasonable copying charges. I further understand that I will be permitted to request access to such documentation and
have any errors in the personal information noted and corrected by formulating a written request to the Company mailed to the employee who is handling my claim.
I acknowledge and agree that if I choose to use, or instruct the Company to use, any electronic communication that is not encrypted, including without limitation, any fax or email communication,
that (i) security, privacy and confidentiality cannot be ensured, (ii) such communication is not reliable and may not be received by the intended recipient in a timely manner or at all, (iii) such
communication could be subject to interception, loss or alteration, and (iv) I assume full responsibility for the risks in connection with such communication and the Company will not be
responsible or liable in any way in connection with such communication, including without limitation, any unauthorized access to or interception, loss or alteration of such communication.
Your Authorization to Disclose Personal Information
I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information, records or other data regarding me, my medical history
or treatment, or my past and present income, employment, education or training, which they have in their possession or control.
Persons to whom this Authorization Applies: Any physician, nurse, counsellor, psychologist, pharmacist, physiotherapist, chiropractor or other rehabilitation professional or other health care
practitioner; and also any hospital, clinic, pharmacy, or other medical facility or provider of health care or treatment; and also the provincial health insurance plan, any insurance company or
other financial institution or insurance broker or administrator; and also my employer or former employers and any of their agents performing services relating to any employee benefits or
workers’ compensation; and also any federal or provincial government department or organization, including the Workers’ Compensation Board/Workplace Safety and Insurance Board, the
CPP/QPP disability/retirement authorities, and the federal or provincial income tax authorities; and also to any other person, agency, credit bureau or institution having information, records or
data regarding me, my medical history or treatment, or my past and present income, employment, education or training.
I understand that any information, records or data received by the Company pursuant to this authorization, both medical and non-medical, will be used for the purpose of determining coverage
under the policy, evaluating my claim for benefits, my ability to return to work and/or for the purpose of assisting with the co-ordination of my return to work, for the purpose of administering the
group and/or individual plans of insurance (including life, accidental death and dismemberment and disability policies of insurance) arranged through my employer with the Company or another
insurer, for the purpose of providing ongoing claim status information to my employer at the time the claim was incurred, for the recovery of any overpayment of benefits incurred by me, if
necessary, or for the purposes of fulfilling its (or RBC Financial Group’s) obligations or investigations with respect to audits, anti-money laundering, terrorist financing, fraud detection, prevention
or suppression or other criminal activities. To the extent reasonably necessary for those purposes, I authorize the Company to disclose any of the said information, records or data received: to
other insurance companies or any reinsurer; or to my employer and their insurance brokers or advisors or their benefit plan administrators; or to my physicians or health care providers; or to
any other person or organization (including physicians, health care practitioners, rehabilitation workers, vocational evaluators) employed or engaged by the Company.
I also authorize the Company to collect, use and disclose, as necessary and relevant, my personal information from any prior claim(s) and/or for any subsequent claim(s).
I also authorize the Company to use my Social Insurance Number for any tax reporting purposes and CPP/QPP purposes and to request information from federal and provincial tax authorities
and for identification purposes when required by policyholders on group LTD/GSI policies.
This authorization does not have any expiry date. It will remain valid for as long as I am claiming eligibility for benefits or services from the Company and while the Company pursues subrogation
rights or the recovery of any overpayment of benefits incurred by me, if necessary, whether or not benefits are being paid, and whether or not either party takes the position that there has been
a breach of contract. A photocopy of this authorization, as executed by me, will be as valid as the original.
Signature of Client Name of Client (Please print) Date (DD/MM/YYYY)
Social Insurance Number:
Signature of Witness Name of Witness (Please print) Date (DD/MM/YYYY)
Send the completed form to our ofce by email: firstname.lastname@example.org
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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