Fillable Refusal of Group Coverage Form Group Benet Solutions (RBC Insurance)

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Refusal of Group Coverage Form Group Benet Solutions (RBC Insurance)

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VPS 105596
110605 (11/2019)
Refusal of Group Coverage Form
Group Benet Solutions
(GBS)
All group coverage with RBC Life Insurance Company (RBCI) must be refused (except as noted below).
The option to refuse coverage by benet is not available (except as noted below).
EMPLOYER SECTION (to be completed by the Employer)
NAME OF EMPLOYER RBCI POLICY #
BILLING
DIVISION #
PLAN MEMBER
ID #
PLAN MEMBER NAME DATE OF BIRTH
Last First Initial
MM/DD/YYYY
REFUSAL ELECTION (To be completed by the Employee)
Please select one of the following options:
r
I understand the Group Benets plan offered to me, but I wish to refuse all of the coverage available to me and my dependents under the above
Policy Number.
r
Due to my religious convictions and observances, I wish to refuse all the group life insurance available to me and my dependents (group basic life,
group dependent life and group optional life as applicable) under the above Policy Number.
r
Province of Quebec only: I am a resident of the Province of Quebec. I am 65 years or older and have elected to receive prescription drug coverage
through the Régie de l’assurance maladie du Québec (RAMQ). I wish to refuse all Extended Health Benets available to me and my dependents
under the above Policy Number.
AUTHORIZATION AND DECLARATION (To be read and signed by the Employee)
I understand that if I and/or my dependents wish to apply for the coverage that I am now refusing, I and/or my dependents will be required to submit
Evidence of Insurability and pay any additional costs associated with my application at my own expense. I understand that such coverage will subject to
approval by RBCI.
Refusal of coverage availability is subject to the provisions in the above Group Master Policy and approval by RBCI.
Employee Signature: Date (MM/DD/YYYY)
Please forward the signed original of this form to RBCI and retain a copy of this form for your records.
RBC Life Insurance Company
PO Box 1600, 8677 Anchor Drive
Windsor, ON N9A 0B3
1-855-264-2174
® /
TM
Trademark(s) of Royal Bank of Canada. Used under licence.
www.rbcinsurance.com
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Refusal of Group Coverage Form Group Benet Solutions (RBC Insurance)

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Completed 21 May 2021

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