Forms

Claim Form for Vision Care Services

Complete this form to submit a claim for vision care expenses such as eye glasses and contact lenses. One form should be used per practitioner, per patient.

Send the completed form, along with itemized receipts that include the information below, to RBC Insurance.

• Patient name
• Copy of vision prescription
• A breakdown of charges for lenses and frames
• Date glasses were picked up

Note: There is no need to attach receipts if this form is completed in full by your provider.

Online Claims Submission
You can also check your eligibility for vision care benefits and submit vision care claims through the Online Group Benefit Solutions service for Plan Members.

Mailing Instructions
If mailing the form, please send to:
RBC Life Insurance Company
Attention: Vision Department
P.O. Box 1603
Windsor, Ontario
N9A 0B6

Wellness Spending Account (WSA) Claim Submission Form

Complete this form to submit a claim for reimbursement under your Wellness Spending Account for eligible expenses.

Send the completed form, along with your original, fully paid receipt and an explanation of the benefit received, to the appropriate address listed on the form.

Be sure to keep a copy of your receipt for your records.

Claim Form for Related Health Professional Services

Complete this form to submit a paramedical claim for services provided by a massage therapist, naturopath, chiropractor, etc.

When completing the form, be sure to include the following information:

• Patient name
• Type of service ie. Chiropractor, massage therapy, etc.
• Individual date and nature of treatment
• Charge for each service

Mail the completed form, along with itemized receipts, to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1603
Windsor, Ontario
N9A 0B6

Online Claims Submission

You may be able to submit this type of claim online. To find out more, sign in to the Online Group Benefit Solutions service for a list of eligible expenses.

Note: You can also check your eligibility for select practitioners and access pre-populated forms through the Online Group Benefit Solutions service for Plan Members.

Claim Form for Medical Devices

Complete this form to submit a claim for a medical device. One form should be used per practitioner, per patient.

For custom-made foot orthotics or custom footwear, please use the Claim Form for Custom Foot Orthotics

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1613
Windsor, Ontario
N9A 0B8

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members

Claim Form for In-Home Support Services of an RN RNA / Private Duty Nursing

Complete this form to submit a claim for in-home nursing services.

*Pre-approval is required for all nursing claims. Please call Customer Service at 1-855-264-2174 for details.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1601
Windsor, Ontario
N9A 0B4

Health Spending Account (HSA) Claim Submission Form

For assistance with filling out the form, please click here.

Complete this form to submit a claim for reimbursement under your Health Spending Account for eligible expenses that are not covered (or not covered in full) by your Health or Dental plan.

For a list of eligible expenses, please visit the Canada Revenue Agency website.

Send the completed form, along with your original, fully paid receipt and an explanation of the benefit received, to the appropriate address listed on the form.

Be sure to keep a copy of your receipt for your records.

Hearing Aid Claim Form

Complete this form to submit a claim for hearing aids. Please note that this form must be filled out for all pay plan member claims.

Send the completed form, along with itemized receipts that include the information below, to RBC Insurance.

• Patient name
• Services and dates
• Audiologist name and address
• Breakdown of charges (i.e. acquisition cost, fee, mold)

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1610
Windsor, Ontario
N9A 0B7

Hospitalization Claim Form

Complete this form to submit a claim for a stay in a semi-private or private hospital room.

When completing the form, be sure to include the following information:

• Patient name
• Number of days in a semi-private/private accommodation
• Rate charged per day
• Admission and discharge dates

Mail the completed form, along with itemized receipts, to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1603
Windsor, Ontario
N9A 0B6

General Claim Submission

Complete this form for all general claims. Detailed instructions for eligible expenses are included on the form.

Send the completed form to the appropriate address listed on the form.

Online Claims Submission

Some claims can be submitted online. To find out more, sign in to the Online Group Benefit Solutions service for a full list of eligible expenses.

Note: You can also check your eligibility for some benefits and access pre-populated forms through the Online Group Benefit Solutions service for Plan Members.

Dental Accident Report Form

Send the complete form along with a predetermination or any incurred claims to:
RBC Life Insurance Company
P.O. BOX 1614 Windsor, Ontario N9A 0B9

Please note x-rays are required.

Dental Claim Form

Complete this form to submit a claim for dental services.

We recommend that you also submit a pre-determination to us first before you receive any service valued over $300. This can help avoid surprises and out-of-pocket expenses in case a certain service isn’t covered.

Send the completed form, along with your original, fully paid receipt, to:
RBC Life Insurance Company
Attention: Dental Department
P.O. Box 1614
Windsor, Ontario
N9A 0B

Be sure to keep a copy of your receipt for your records.

Online Claims Submission

Your dentist may also be able to submit claims to us on your behalf, and confirm if you owe any amounts due to deductibles and reimbursement levels. We will pay your dentist directly.

If you have the Deferred Payment option, you must pay your dentist in full and your dental office can then submit the claim to us electronically. Reimbursement will be sent directly to you.

Note: You can also check your eligibility for this benefit and access pre-populated forms through the Online Group Benefit Solutions service for Plan Members.

Claim Form for Custom Foot Orthotics

Complete this form to submit a claim for custom foot orthotic expenses such as shoes and inserts. Please note that the details requested on this form are mandatory.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1610
Windsor, Ontario
N9A 0B7

Note: You can check your eligibility for this benefit online through the Online Group Benefit Solutions service for Plan Members.

Chronic Care / Alternate Level of Care Claim

This form must be completed by a Hospital Official and should be forwarded to our office (Attn: Hospital Claims Department) after the month for which the co-payment fee applies.

An assessment to determine eligibility for a reduced rate must be completed by a Hospital Official and copies of the results MUST be forwarded with the initial claim. The hospital will have a supply of the assessment forms as they are provided by the Ministry of Health directly to the hospital.

Send the completed form to:
RBC Life Insurance Company
P.O. Box 1603
Windsor, Ontario
N9A 0B6

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members.

Authorization Form for Prosthetic Appliances and Durable Medical Equipment

Complete this authorization form to request prior approval of claims for prosthetics.

*Please note that the details requested on this form are mandatory and that a claim may be denied without prior authorization.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1610
Windsor, Ontario
N9A 0B7

After reviewing your request, we will send you a response letter outlining your eligibility as soon as possible.

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members.

Authorization Form for Post-Cataract Surgery and Prosthetic Eye Wear

Complete this authorization form to request prior approval of claims for post-cataract surgery and prosthetic eye wear.

*Please note that a claim may be denied without prior authorization.

Mail the completed form to:
RBC Life Insurance Company
P.O. Box 1603
Windsor, Ontario
N9A 0B6

Authorization Form for Oxygen Equipment and Supplies

Complete this authorization form to request prior approval of claims for oxygen equipment and supplies.

*Please note that a claim may be denied without prior authorization.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1610
Windsor, Ontario
N9A 0B7

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members.

Authorization Form for In-Home Support Services of an RN RNA

NOTE: To open this PDF, you will need to copy the PDF link and paste it into the Open File dialogue box in Adobe.

Complete this authorization form to request prior approval of claims for in-home support services.

*Please note that the details requested on this form are mandatory and that a claim may be denied without prior authorization.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1613
Windsor, Ontario
N9A 0B6

Fax: 1-855-612-3031

Authorization Form for Custom Braces

Complete this authorization form to request prior approval of claims for custom braces.

*Please note that the details requested on this form are mandatory and that a claim may be denied without prior authorization.

Mail the completed form to:
RBC Life Insurance Company
Attention: EHS Department
P.O. Box 1610
Windsor, Ontario
N9A 0B7

After reviewing your request, we will send you a response letter outlining your eligibility as soon as possible.

Note: This form is available, pre-filled with your personal details, within our Online Group Benefit Solutions service for Plan Members.

Loss of Use / Dismemberment Notice of Claim

When an insured individual is making a claim for dismemberment, loss of use, loss of sight, etc., he or she will need to complete the appropriate sections of this form.

Note: The form also includes sections that must be completed by the insured individual’s employer and physician.

Please follow these steps to complete and submit this form:

Employee Instructions:

• 1. Complete the Claimant’s/Employee’s Statement section within this form and return to your employer.
• 2. Complete and sign the Authorization section on the Attending Physician’s Statement, and send this form to your treating physician for completion. The form can be returned directly to RBC Insurance once completed.

Employer Instructions:

Complete the following sections within this form:

• Employer’s Statement
• Claimant’s/Employee’s Statement
• The original enrolment form

Mail the completed form to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Group Life/Accidental Death Notice of Claim

When a beneficiary is making a life or accidental death claim on behalf of a deceased and insured individual, the beneficiary, the deceased’s employer and the deceased’s physician must complete the appropriate sections of this form.

Please follow these steps to complete and submit this form:

Beneficiary Instructions

1. Complete the claimant section of the form.
2. Return the form to the insured’s employer for completion.

Instructions for the Employer of the Insured

1. Complete the employer section and sends all forms, along with original enrolment form and any change of beneficiary form(s) to RBC Insurance.

Mail the completed form(s) to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Spouse Disability Notice of Claim

When submitting a spousal disability claim, your spouse will need to complete this statement.

Note: The form also includes sections that must be completed by your employer and the treating physician.

Please follow these steps to complete and submit this form:

Claimant Instructions:

1. Ensure that the Employer’s Statement is completed.
2. Complete the Spouse’s Statement and return along with the Employer’s Statement to RBC Insurance.
3. Send the Attending Physician’s Statement to the treating physician and have this for returned to RBC Insurance.

Employer Instructions:

1. Complete the Employer’s Statement and attach Proof of Enrolment.
2. Send this form along with the Spouse’s Statement and the Attending Physician’s Statement to the claimant.

Mail the completed form(s) to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Client’s Supplementary Statement

Your employer must complete this form if you are making a disability claim.

Mail the completed form to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Long Term Disability Group Claim Form – Employer Statement

Your employer must complete this form if you are making a disability claim.

Mail the completed form to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Long Term Disability Group Claim Form – Client’s Statement

Your employer must complete this form if you are making a disability claim.

Mail the completed form to:
RBC Life Insurance Company, Life & Health Claims Department
P.O.Box 4435, Station A
Toronto, Ontario
M5W 5Y8

Or Fax to:
1-800-714-8861

Short Term Disability Claim Form – Physician Statement

Choose the Form: Attending Physician’s Statement Short-term Disability.

Short Term Disability Claim Form – Employer Statement

Short Term Disability Claim Form – Client’s Statement

For all travel insurance inquiries or claim forms, please contact Allianz Global Assistance:

Visit: Online Travel Insurance Claims Site

or

Call:

Assistance

• 1 855-603-5571 (Canada and USA)
• 905-608-8251 (collect from anywhere)

Claims:

• 1 855-603-5574 (Canada and USA)
• 905-608-8254 (collect from anywhere)

Travel Confirmation of Coverage Letter

Prior to travelling, review your Employee Benefits Booklet to understand what your benefits cover. Take this letter along with your RBC Insurance ID card with you when you travel to countries requiring proof of coverage. Please call 1-855-264-2174 if you require a personalized detailed letter.

Request to Exercise Portability Privilege

NOTE: To open this PDF, you will need to copy the PDF link and paste it into the Open File dialogue box in Adobe.

Claim form

Form/document instructions:

NOTE: To open this PDF, you will need to copy the PDF link and paste it into the Open File dialogue box in Adobe.