Fill - Free fillable RBC Life Insurance Company (RBC Insurance) PDF form

RBC Life Insurance Company

Client’s Supplementary Statement

INFORMATION ABOUT YOU

Full Name (Last, First, Middle Initial):

Policy Number: Claim Number:

Address

(Apt./Street/City/Province/Postal Code):

Home Telephone Number: Work Telephone Number:

Email Address: Cell Phone Number:

INFORMATION ABOUT YOUR CLAIM

What is your current diagnosis? Primary:

Secondary:

What are your current symptoms?

How do your current symptoms prevent you from working?

Describe your current activities and how your condition or symptoms impacted these activities:

What are your activity restrictions (what you SHOULD NOT do)?

What are your activity limitations (what you CANNOT do)?

Are there any new restrictions or limitations that have been recommended by your attending physician(s)?

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Yes

Primary physician’s name:

List other physician’s and/or therapists consulted:

Name and Specialty Address Telephone Number

Date(s) Seen

(DD/MM/YYYY)

Have you been hospitalized since your last Statement? c c No

If “Yes”, from: to:

Reason:

Hospital name and address:

Provide a list of all current treatment including medications/dosages, therapy, and/or rehabilitation programs:

Do you feel that the treatment has helped, or is likely to be helpful?

Have you returned to school or taken any courses? c Yes c No

If “Yes”: c Full-time Date started

(DD/MM/YYYY):

c Part-time

Degree/certificate, etc received? c Yes c No

If “Yes”, provide details and completion date:

Have you participated in volunteer work or travelled (domestic or international)? c Yes c No

If “Yes” to travel: Date(s) of travel and destinations(s):

If “Yes” to volunteer work: c Full-time Date started

(DD/MM/YYYY):

# of hours:

Part-time

c Week c Month c Other:

Provide details:

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Yes

Since your last Statement, have you engaged in any employment related activities on either a paid or unpaid basis?

c Yes c No

If “Yes”, to the same job? If “Yes”: Date started

(DD/MM/YYYY): # of hours:

c c No

c Full-time c Part-time

Provide details:

Describe your business affiliations (e.g. employer, self-employed, partner, online/home based

business, etc) and provide details:

If you are currently working, have your regular duties been modified due to your condition?

c c No If “Yes”, describe:

If “No”, have you made any

effort or investigation, including

discussion with your attending

physician about attempting to

return to work?

If “Yes”, provide details, including what you believe to be modifications to accommodate a return to

work in some way:

c c No

Have you applied for, or receiving, an income from any of the following?

Yes/

Date Filed

(DD/MM/YYYY)

Date Payments Began

(DD/MM/YYYY)

Sources of Income

Policy No. Amount

WCB / WSIB / CSST Benefits $

CPP / QPP Disability Pension Plan

Benefits

Retirement Pension $

Automobile or Disability Insurance $

Other (specify): $

Please provide copies of all correspondence received if any information has changed since last update.

IMPORTANT: If your benefit is taxable, please complete these two fields regarding exemption amounts (claimed) for Federal tax

$ and Provincial tax $ by completing the required tax forms available at the CRA website:

https://www.canada.ca/en/revenue-agency/services/forms-publications/td1-personal-tax-credits-returns.html.

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FRAUD NOTICE

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

(Print name)

best of my knowledge and belief.

Signature of Client Date (DD/MM/YYYY)

AUTHORIZATION

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 ofce by email: intake@rbc.com

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

www.rbcinsurance.com

® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.

VPS 107827

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