Registered trademarks of Royal Bank of Canada. Used under licence. Critical Illness Supplement ( )

Transcription

1 Registered trademarks of Royal Bank of Canada. Used under licence. Critical Illness Supplement ( )

2 Proposed Life Insured (If joint application, complete separate application for each life) Critical Illness Supplement to: Application Number Policy Number Please submit with Application for Insurance or Application for Policy Change, Reinstatement or Reissue. 1. Last Name First Name Initial Date of Birth (day/month/year) Critical Illness Insurance applied for 2. Amount Coverage $ To age 75 Lifetime Existing or Pending Insurance 3. a) Critical Illness Insurance in force? Year Issued Company Yes No Amount of Critical Illness Insurance b) Complete only if change or reinstatement. Amount of Life Insurance Including Term Riders Personal Business Personal Business Is the insurance applied for intended to replace any insurance now in Amount of force with any company? Disability Income and Creditor Insurance Yes No 4. a) Has any application for critical illness insurance been declined, rated, cancelled or modified in any way? If yes, please explain. Yes No 4. b) Complete only if applying for policy change or reinstatement. Has any application for life, disability or creditor insurance been declined, rated, cancelled or modified in any way? Yes No If yes, please explain. Family History 5. Have any of your immediate family members (father, mother, siblings) had heart disease, stroke, cancer (specify type), diabetes, kidney disease, mental illness, alcoholism, Huntington Disease, amyotrophic lateral sclerosis (Lou Gehrig Disease), motor neuron disease, multiple sclerosis, Alzheimer, Parkinson Disease, Hepatitis or any other hereditary disease? Yes No If yes, complete section below and indicate family member, condition, age at onset and if applicable, age at death. Family Member Condition Age at Onset Age if Living Age at Death Cause of Death RBC LIFE INSURANCE COMPANY PPI BUSINESS GROUP UNDERWRITING JULY 21, 2005 PAGE 1 OF 4

3 Confidential Financial Questionnaire 6. Complete when pending or total amount to be in force with all companies exceeds $250,000 of personal critical illness insurance or for any amount of business critical illness insurance. PERSONAL INSURANCE ANNUAL INCOME: Earned (after expenses) Unearned Source ASSETS: Real Estate LIABILITIES: Mortgage Business Equity Stocks/Bonds Cash in Bank Other (specify) Loans Other NET WORTH: BUSINESS INSURANCE Nature of the business Number of years in operation Title and job duties of Proposed Life Insured % Ownership, if any KEYMAN COVERAGE Salary Bonus EQUITY PURCHASE WHERE APPLICABLE: PARTNERS & % OWNERSHIP (buy/sell, stock redemption) Net worth of the company (Fair market value) Year Business net income: current year previous year AMOUNT OF INSURANCE IN FORCE/APPLIED FOR CREDITOR OTHER Amount of loan and lender Provide details I declare that the above statements and answers are complete and true and shall form part of the application for Critical Illness insurance to RBC Life Insurance Company. I understand that this Critical Illness Supplement forms part of the contract of insurance as outlined under the Declarations, Agreements & Consents section of the basic Application. I understand that the conditions insured under the Critical Illness insurance applied for are only those conditions as defined in the policy and that the benefit is payable to the Proposed Life Insured unless otherwise specified. Signature of Applicant (if other than Proposed Life Insured) Signature of Proposed Life Insured Signature of Witness RBC LIFE INSURANCE COMPANY PPI BUSINESS GROUP UNDERWRITING JULY 21, 2005 PAGE 2 OF 4

4 Interim Critical Illness Insurance (Available only if applying for an amount of Critical Illness Insurance that is $500,000 or less) No interim Critical Illness Insurance can take effect unless Temporary Life Insurance or Interim Life and Income Replacement Insurance takes effect under the Receipt and Agreement contained in the basic Application. The terms and conditions for interim Critical Illness Insurance are those stated in the Interim Critical Illness Insurance Receipt and the Agreement attached. The terms and conditions of the Temporary Life Insurance Agreement or the Interim Life and Income Replacement Insurance Agreement are not applicable to Critical Illness Insurance. Interim Critical Illness Insurance Statement of Insurability Questions relating to the insurability of the Proposed Life Insured are in addition to the questions on the Statement of Insurability for Temporary Life Insurance or Interim Life and Income Replacement Insurance. 1. Has the Proposed Life Insured ever been treated for or had any indication of cancer, stroke, heart disease, disorder of the immune system, AIDS (Acquired Immune Deficiency Syndrome) or AIDS Related Complex (ARC), had a positive test for antibodies to the Human Immunodeficiency Virus (HIV), chronic kidney, liver, lung or neurological diseases? 2. Has any application for critical illness ever been declined, rated, postponed or modified in any way? Yes No If question 1 or 2 is answered Yes or is not answered, the representative has no authority to take or accept a premium on behalf of or as representative of the Company and no Critical Illness Insurance will be provided even if money is paid. I/We declare that the above questions have been truthfully answered. Signature of Applicant (if other than Proposed Life Insured) Signature of Proposed Life Insured (Use this form as a Supplement to the basic Application for Life Insurance) Policy Number Interim Critical Illness Insurance Receipt The receipt under the basic application acknowledges the amount received by the Company. If the amount includes a charge for Critical Illness, Interim Critical Illness Insurance will be provided under the terms and conditions of the Interim Critical Illness Insurance Agreement on the reverse side. Interim Critical Illness Insurance is provided on the effective date of the Temporary Life Insurance Agreement or the Interim Life and Income Replacement Insurance Agreement, whichever is applicable. The payment for which this receipt is given must be made on or prior to the date of completion of the basic application. No Interim Critical Illness Insurance is provided if the amount of Critical Illness Insurance applied for exceeds $500,000. No representative or person other than an officer of the Company is authorized to waive or modify the requirements for payment or the conditions or limits in this Receipt or in the Agreement on the reverse side. Signature of Representative RBC LIFE INSURANCE COMPANY PPI BUSINESS GROUP UNDERWRITING JULY 21, 2005 PAGE 3 OF 4

5 Interim Critical Illness Insurance Agreement If the terms, conditions and requirements on the reverse side are met, RBC Life Insurance Company, (the Company) agrees to insure the Proposed Life Insured, subject to the limits in amount and the conditions governing commencement and termination set out below. Interim Critical Illness Insurance Critical Illness is as defined and governed by the Company s standard form of policy. Interim Critical Illness Insurance commences on the effective date only if evidence of insurability exists on that date which, whenever available, enables the Company to determine that any Proposed Life Insured is or was eligible for such insurance under its usual underwriting rules and practices. Subject to a maximum aggregate of $500,000 under this or other Interim Critical Illness Agreements issued by the Company, the Company will pay the LESSER OF : (a) The amount of critical illness benefits for which the Proposed Life Insured would have been eligible under the policy applied for and (b) $500,000 Termination of Interim Critical Illness Insurance Interim Critical Illness insurance hereunder terminates automatically on the EARLIEST OF: (a) 90 days from the date of the Receipt on the reverse side, (b) the date notice is given by the Company to the Applicant that the application is not accepted as applied for (Notice by mail being deemed to have been received two days following the date of mailing), (c) the date a policy issued by the Company is tendered for delivery and (d) the date the policy goes in force. Payment received by the Company is refundable under (a) or (b). Limitations (a) No insurance takes effect and the Company s only liability is to refund the payment if there is material misrepresentation or nondisclosure in the application. (b) The Company shall have no liability if the Proposed Life Insured, while sane or insane, becomes critically ill as a result of selfinflicted injury. (c) No insurance takes effect if the Proposed Life Insured is diagnosed with cancer under the critical illness definition or diagnosed with any other defined critical illness and death occurs from this illness within 30 days of the diagnosis. (d) No Critical Illness Insurance shall go into force under the policy applied for if there has been a change in the health or insurability of any Proposed Life Insured before the policy would otherwise take effect. However, subject to the limitations in respect of cancer and the 30-day period stated in (c) above, the Company will issue its standard form of policy and pay the Critical Illness Insurance benefits if there is a change of health which is diagnosed as a critical illness while this Agreement is in force and prior to the policy s taking effect. RBC LIFE INSURANCE COMPANY PPI BUSINESS GROUP UNDERWRITING JULY 21, 2005 PAGE 4 OF 4 Registered trademarks of Royal Bank of Canada. Used under licence.