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