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

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.