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Statement of Disability
WHAT WE REQUEST AND WHY
Your patient is applying for disability benets under a policy of disability insurance underwritten by RBC Life Insurance Company.
As you can appreciate, the information provided by you is important to our adjudication of your patient’s claim. We are asking for your
cooperation in providing pertinent information regarding the diagnosis, signs and symptoms, as well as details of your patient’s limitations and
We ask that you complete the Attending Physician’s Statement as thoroughly as possible. Please be assured that the information, including
the medical records requested, is required for the adjudication of your patient’s claim and will be treated condentially.
RBC Life Insurance Company is requesting copies of your complete le for the period of treatment for this condition, including
specialist consultations, ofce notes, test results, hospital admission histories, discharge summaries and medical reports prepared
for other insurers on your patient and is prepared to reimburse $50.00 for the costs associated with preparing the information.
If this amount is unreasonable because of the extent of your patient’s le, please have your staff contact our ofce at 416-643-4700 or
toll free at 1 877-519-9501. Any charge for the completion of this form, however, is the responsibility of the patient.
We would like to thank you in advance for your cooperation.
Part 1: PATIENT INFORMATION
Name: Last First
Address (Street / City / Province / Postal Code)
Date of Birth (DD/MM/YYYY)
Please attach copies of all consultation, operative and
Part 2: DIAGNOSIS OF PRESENT CONDITION
Primary: Rheumatoid Arthritis Osteoarthritis Other Rheumatic disease
Please specify other:
Additional conditions / complications:
Current Height: Current Weight: Weight loss/gain to date:
In your opinion when did the patient’s condition rst prevent him/her from working? (DD/MM/YYYY)
Please provide the names of other physicians who have been/will be involved in assessing the medical problems, and copies
of any available consultation reports:
Test Date (DD/MM/YYYY) Result
Rheumatoid factor titre
Positive synovial uids
Histological change from biopsy