Claim And Authorization Form (Page 2 of 3) in pdf

OTHER INSURANCE INFORMATION – TRIP INTERRUPTION

This section must be completed by the insured person. If the insured is a minor, the parent/legal guardian can complete this section

Other than your coverage with us, do you, your spouse or your parents (if you are a dependent) have any other insurance coverage?

1. Other Travel Plans

YES

NO - if YES, please complete Section 1 below

2. Credit Cards (that were used to purchase your trip)

YES

NO - if YES, please complete Section 2 below

Section 1 –

To help you receive all payments you are entitled to, we will co-ordinate with any other insurers on your behalf

Name of Policyholder:

Name of Insurance Company:

Policy number:

Section 2 –

To help you receive all payments you are entitled to, we will co-ordinate with any other insurers or Credit Card coverage that may provide

similar benefits on your behalf.

Name of Cardholder:

Relationship to Cardholder:

Type of credit card:

Credit card number:

AUTHORIZATION

1. I hereby assign to RBC Insurance Company of Canada any benefits obtainable from other sources for losses covered under this policy. I

also direct these sources to forward payment to RBC Insurance Company of Canada for my claim submitted by RBC Insurance Company

of Canada with regard to these losses. A photocopy or faxed copy of this authorization is acceptable.

2. I understand my claim may be subject to review and investigation and I give RBC Insurance Company of Canada or their authorized agents

authority to acquire any documents or statements from other insurers, financial institutions, travel suppliers, any company or public/private

organization which can provide information related to my claim, and I hereby consent to the disclosure of such information by RBC Insurance

Company of Canada to other sources as may be required for the processing of my claim.

3. I authorize you to give RBC Insurance Company of Canada any and all information you have regarding me, while under observation or

treatment by you, including my medical history, diagnoses and test results, and I hereby consent to the disclosure of such information by RBC

Insurance Company of Canada to other sources as may be required for the processing of my claim for benefits obtainable from other

sources.

4. I hereby consent to the disclosure so such information to the following people listed: (please specify relationship)

Name:

Relationship:

Name:

Relationship:

Print Name of Claimant/Designated Legal Representative

Signature of Claimant/ Designated Legal Representative

Date

A copy of this authorization shall have the same authority as the original.

Claim And Authorization Form Page 2