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VPS 92474
87256 (08/2015)
ROYAL RECOVERASSIST
®
HOSPITAL BENEFIT CLAIM FORM
Instructions for
completing this form
This form should be completed by the
Client (Insured Certificate holder) and
the Attending Physician.
Please follow these instructions for
completing the form:
Client’s Statement
• Client completes 1, 2, 3 and 4.
• Hospitalized Insured Person 16
years of age or older (if different from
client) completes 2, 3 and 4.
Attending Physician’s Statement
• Physician completes.
We will accept copy of driver’s license or
passport as proof of age.
Please note that any charges incurred for
completion of this form are at the expense of
the client.
You must include a fully itemized state-
ment of account from the hospital show-
ing the date(s) of your confinement. Your
claim will not be processed without this
document.
Send the completed original claim form
and all other required documents to:
RBC Life Insurance Company
P.O. Box 4435, Station A
Toronto, Ontario
M5W 5Y8
Telephone: 416-643-4700
Toll free: 1-877-519-9501
Fax: 1-800-714-8861
Incomplete claim forms will be
returned for completion.
Please allow 10-15 days for your claim
to be processed.
Page 1 of 5
VPS 92474
87256 (08/2015)
ROYAL RECOVERASSIST
®
CLIENT’S STATEMENT
Insured person’s name (last, first, initial) Insured’s date of birth (DD/MM/YYYY)
(provide copy of birth certificate)
1 Personal
information
Client’s name (last, first, initial) Client’s date of birth (DD/MM/YYYY)
(provide copy of birth certificate)
Certificate number Relationship to client:
Self Spouse Child*
* If child is 19 years or older, are they:
Disabled Full-time student**
** If full-time student, please provide proof of enrollment at an accredited institute of learning.
Client’s address (number, street and apt. number)
City Province
Postal code
Client’s residence telephone number
(
Client’s business telephone number
( ) )
2 Details of
hospital stay
Were you confined to a hospital for your present condition? Yes* No
*
If “Yes,” please provide the period of confinement: From (DD/MM/YYYY) To (DD/MM/YYYY)
Hospital
name Hospital address
Indicate the type of hospital stay:
Out-patient In-patient Day surgery
Other (specify)
In what unit(s) of the hospital were you confined?
Intensive care
Intensive coronary care
Coronary care
Palliative care
Rehabilitative care
Convalescent care
Chronic care
Emergency
When was surgery or hospitalization first discussed
with your doctor? (DD/MM/YYYY)
When was the hospital room booked? (DD/MM/YYYY)
Was surgery performed for cosmetic reasons? Yes
No
Details of condition
Nature of condition
Specify the reason for your hospital stay:
Sickness Injury
Diagnosis/nature of condition
Date symptoms of this condition were first noticed
(DD/MM/YYYY)
If sickness
Date of first medical treatment or advice for this condition (DD/MM/YYYY)
If injury
Date of injury (DD/MM/YYYY)
Describe injury
If you were injured
in a motor vehicle
accident
Name of the driver of the vehicle in which you were travelling
Name and address/division of the police officer notified
Was a police report prepared?
Yes* No * If “Yes,” please attach a copy of the report.
Page 2 of 5
VPS 92474
87256 (08/2015)
ROYAL RECOVERASSIST
®
ATTENDING PHYSICIAN’S STATEMENT
1 Hospital
admission
details
Patient’s name (last, first, initial) Date of birth (DD/MM/YYYY)
Certificate number
Date of hospital inpatient admission
(DD/MM/YYYY) Date of hospital discharge (DD/MM/YYYY)
Date of surgery (DD/MM/YYYY)
Nature of surgery
Diagnosis most
responsible for
this hospital
admission
Primary condition
Secondary condition (if applicable)
If due to
sickness
(directly or
indirectly)
Was sickness a contributing cause of this admission? Yes No
Date of first consultation for any manifestation of this condition
(DD/MM/YYYY)
Date the diagnosis was first made
(DD/MM/YYYY)
Has patient ever had the same or similar condition? Yes* No
* If “Yes,” please state when and describe.
If due to injury
Is the condition primarily due to an accident? Yes* No Date of accident (DD/MM/YYYY)
* If “Yes,” please specify: Motor vehicle accident Work-related incident Other
Please provide details of the accident.
Medical care
Are you actively treating the patient? Yes No Date of last consultation (DD/MM/YYYY)
Frequency of visits: Weekly Monthly Other (specify)
If the patient is pregnant, please provide the expected date of confinement.
(DD/MM/YYYY)
Describe any pathological complications of pregnancy.
Previous
medical
care
Give
details
of
prior
visits
by
the
patient
for
the
current
disabling
condition
(include
dates,
the
presenting
signs
and
symptoms,
the
diagnostic
findings,
and
treatments).
If the patient was referred to you, please
indicate name of the referring physician.
Page 3 of 5
VPS 92474
87256 (08/2015)
 
 
 
 
__________________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Doctors con-
sulted in
the past
Have you ever had this or a similar condition before? Yes* No
* If “Yes,” give details including name, address and telephone number(s)
of doctor(s) and dates of treatments.
Family physician’s name
Address Telephone number
( )
List the names, addresses and telephone numbers of ALL other doctors you have consulted during the
past five years.
3 Declaration
Did you smoke during the 12 months prior to the date of hospitalization?
* If “Yes,” please specify:
Cigarettes
Pipe
Cigars
Client’s signature
Yes* No
I understand that this declaration is a material
statement and the Company will rely upon its truth in
assessing the claim.
Date signed
(DD/MM/YYYY)
Witness’s signature Date signed (DD/MM/YYYY)
Confidentiality
All information requested will be for the purpose of processing and adjudicating your claims and will be treated as
confidential.
To protect the confidentiality of this information, RBC Insurance
®
will establish a “Claim File” from which this
information will be used to process your claims.
Access to this file will be restricted to RBC Insurance’s employees, service providers and representatives who are
responsible for the investigation of claims and to any other person you authorize or who is authorized by law.
Your file is secured and will be kept in the offices of RBC Insurance and its service providers.
4 Authorization
I certify that the information in the form is true and complete to the best of my knowledge.
I understand that RBC Insurance, its service providers and representatives may investigate this claim.
I authorize any licensed physician, medical practitioner, health care professional, hospital, health care institution,
medical organization, clinic and any medically related facility, insurance company, the Medical Information Bureau,
corporation, organization, institution, association or person to release and exchange with RBC Insurance, its service
providers and representatives any medical or benefit payment information, or any other information or records that
may be requested by RBC Insurance, its service providers and representatives to establish or review the validity of
this claim.
I agree that a photocopy of this authorization shall be as valid as the original.
Client’s name
Client’s signature Date signed
(DD/MM/YYYY)
Insured’s name (if different from above)
Insured’s signature Date signed
(DD/MM/YYYY)
Page 4 of 5
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VPS 92474
87256 (08/2015)
 
Did your patient smoke during the 12 months prior to the date of hospitalization?
Additional re-
marks regarding
your
patient’s condition
Yes* No Unknown
* If “Yes,” please specify:
Cigarettes Pipe Cigars
Attending physician’s name (please print) Specialty
Address (number, street and suite number)
City Province Postal code
Telephone number
(
Fax number
() )
Signature of physician Date signed
(DD/MM/YYYY)
Fee: The patient is responsible for securing this form and for charges made for its completion.
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
Page 5 of 5
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Completed 21 May 2021

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