Plan Member Resources

Complete this new claim application package to make a claim for short term disability or accident weekly income benefits.

Note: The application package also includes sections that must be completed by your employer and physician.

Mail the completed claim package 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

Complete this form to make a claim for disability benefits.

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

Complete this form to make a claim for disability benefits.

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

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

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

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:

• Complete the Claimant’s/Employee’s Statement section within this form and return to your employer.
• 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

Complete this form when submitting a claim for critical illness insurance benefits. The form also includes a section to make a claim for return of premium upon death if this is covered under the policy.

Please follow these steps to complete and submit this form:

Critical Illness Claim:

1. Complete all sections within this form
2. Mail completed form to RBC Insurance

Return of Premium on Death:

1. Complete sections A, E and F only
2. Attach a Funeral Director’s Statement
3. Mail completed form and Funeral Director’s Statement to RBC Insurance.

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

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

When submitting a disability or critical illness claim, your physician must complete this supplementary statement.

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

When submitting a disability claim, you must have your attending physician complete one of the following forms.

If you are not sure which form is appropriate, use the General Statement:

• General Statement Form
• Cancer Statement Form
• Cardiac Statement Form
• Musculoskeletal Statement Form
• Psychiatric Statement Form
• Rheumatology Statement 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

When submitting a claim for critical illness benefits, you must have your attending physician complete this condition-specific form.

• Alzheimer’s Disease
• Blindness
• Cancer
• Cardiovascular
• Coma
• Deafness
• Kidney Failure
• Loss of Speech
• Major Burns
• Major Organ Transplant
• Motor Neuron Disease
• Multiple Sclerosis
• Occupational HIV Infection
• Paralysis and Loss of Limbs
• Parkinson’s Disease

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

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

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.

Complete this form to submit a claim for audio expenses such as 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

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.

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.

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.

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.

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

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.

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 0B9

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.

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.

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.

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.

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.

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

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

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.

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

Complete the following steps to submit a travel emergency medical claim.

• Complete and sign the Claim and Authorization Form. Mail the form, along with all applicable documents outlined below, to the claims office:

  RBC Insurance Company of Canada
  P.O. Box 97, Station A
  Mississauga, Ontario L5A 2Y9

• Complete the appropriate provincial health form, if applicable:

  • Residents of British Columbia
    • Out-of-Country Claim Form
    • British Columbia Medical Services Plan (MSP) Schedule A
  • Residents of Newfoundland and Labrador
    • Out-of-Province Claim Form (Required if treated as an outpatient, either at a clinic or hospital.)
  • Residents of Quebec
    • Application for Reimbursement

• Attach all original itemized bills and receipts to support your claim.

• Attach any medical records you may have been given at the time of treatment. For hospitalization claims, we require a complete copy of your medical records from the treating facility.

• For Multi-Trip Annual plans, attach proof of both departure from and return to your province of residence. The type of proof depends on whether you travelled via airline or car.

• For hospitalization claims, we will require a complete copy of your medical records from the treating facility.

Please note: Depending on the claim, we may request more information.

If you need to cancel your trip you will need to complete the following steps to submit your claim:

• Call your travel agent, airline, tour company or the carrier immediately to cancel your trip (no later than one business day after the cause of cancellation).

• Notify us by calling one of the numbers below:

  • 1-855-603-5571 (toll-free from Canada or U.S.)
  • (905) 608-8251 (collect call from anywhere)

• Complete and sign the Claim and Authorization Form.

  Mail the form, along with all applicable documents outlined below, to:

  RBC Insurance Company of Canada
  P.O. Box 97, Station A
  Mississauga, Ontario L5A 2Y9

• If the cancellation is due to an injury or sickness of yourself, an immediate family member or your travelling companion, you must have a Medical Certificate fully completed by the treating physician. The physician who fills out the certificate must be the same one who treated the sick or injured person on the date of the cause of cancellation.

• If the medical condition is for yourself or your spouse, you will also need to provide your family physician's clinical notes from the 90 days prior to your insurance application date up to the present date.

• Submit an itemized copy of your invoice, providing a breakdown of the cost of your trip including airfare, hotel, taxes, service fees, and anything else. You'll need to provide proof of payment for each item.

• Attach original unused airline ticket(s) and any other original travel documents. If you received a refund from your travel agent or travel supplier, you'll need to provide a copy of the statement or refund.

• If cancelling for non-medical reasons, you'll need to provide substantiated evidence. This could be a copy of subpoena for court/jury duty, a letter from your employer, a report from your airline/cruise, or a death certificate.

If you had to return home early from your trip due to a sickness, injury or another unexpected covered situation that occurred during your trip, follow these steps to submit a Trip Interruption Insurance claim:

• Complete and sign the Claim and Authorization Form.

  Mail the form, along with all applicable documents outlined below, to:

  RBC Insurance Company of Canada
  P.O. Box 97, Station A
  Mississauga, Ontario L5A 2Y9

• If the interruption is due to an injury or sickness of yourself, an immediate family member or your travelling companion, you must have a Medical Certificate fully completed by the treating physician at your travel destination. The physician who fills out the form must be the same one who treated the sick or injured person at your travel destination.

• Submit an itemized copy of your invoice, providing a breakdown of the cost of your trip including airfare, hotel, taxes, service fees, and anything else. You'll need to provide proof of payment for each item.

• Attach original unused airline ticket(s) along with the new return tickets you purchased. If you paid a change fee, you'll need to include the original receipts for this cost.

• If the interruption is due to non-medical reasons, you'll need to provide substantiated evidence. This could be a copy of subpoena for court/jury duty, a letter from your employer, a report from your airline/cruise, or a death certificate.

• If you incurred additional expenses as a result of one of the insured risks, you'll need to submit original receipts for all additional costs such as hotel accommodations, meals, essential telephone calls, or taxi fares.

If you had to return home early from your trip due to a sickness, injury or another unexpected covered situation that occurred during your trip, follow these steps to submit a Trip Interruption Insurance claim:

• Complete and sign the Claim and Authorization Form.

  Mail the form, along with all applicable documents outlined below, to:

  RBC Insurance Company of Canada
  P.O. Box 97, Station A
  Mississauga, Ontario L5A 2Y9

• If the interruption is due to an injury or sickness of yourself, an immediate family member or your travelling companion, you must have a Medical Certificate fully completed by the treating physician at your travel destination. The physician who fills out the form must be the same one who treated the sick or injured person at your travel destination.

• Submit an itemized copy of your invoice, providing a breakdown of the cost of your trip including airfare, hotel, taxes, service fees, and anything else. You'll need to provide proof of payment for each item.

• Attach original unused airline ticket(s) along with the new return tickets you purchased. If you paid a change fee, you'll need to include the original receipts for this cost.

• If the interruption is due to non-medical reasons, you'll need to provide substantiated evidence. This could be a copy of subpoena for court/jury duty, a letter from your employer, a report from your airline/cruise, or a death certificate.

• If you incurred additional expenses as a result of one of the insured risks, you'll need to submit original receipts for all additional costs such as hotel accommodations, meals, essential telephone calls, or taxi fares.

Take this letter along with your RBC Insurance ID card with you when you travel to countries requiring proof of coverage.

Important Note: Full details of the coverage are included in your Employee Booklet. Certain limitations and exclusions apply, as outlined in your Employee Booklet. Please review carefully.