RBC - YAM Life Insurance

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PART 1: PERSONAL AND EMPLOYMENT INFORMATION
(You/Your refers to the Proposed Insured)

PROPOSED INSURED

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Smoker

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Product Code

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Term Coverage

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Coverage Amount

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Sex_Quote

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Monthly Premium

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Date of Birth ( Pass)

Day

Month

Year

Title*

Other

Print name as legally known:

Last Name*

First Name*

Middle Name

Former Name

Birthdate:

Day*

Month*

Year*

Birthplace: Country*

Sex*

Male

Female

Sex*

Male

Female

Smoking*

Smoker

Non-Smoker

Smoking*

Smoker

Non-Smoker

Do You understand English or French?*

Yes

Please ensure a Statement of Understanding is signed by the Proposed Insured and the Proposed Owner(s) and submitted with this Application.

Is a French language Policy requested?*

Yes

Residency*

Canadian Citizen

Permanent Resident

Other

Please specify*

How long have You resided in Canada?

Years*

Months

Home Address:

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Civic No.

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Suite No.

Number/Suite Number

Street*

City*

Province*

Postal Code*

Email Address*

Home Phone

Work Phone

Mobile Phone Number

Phone Number

Business/Employer

Name*

Business/Employer Address: Suite No.

Street*

Province*

Postal Code*

City*

Phone No.

Occupation*

Describe nature of business*

Describe duties*

How long with this employer?*

Main Purpose of Insurance

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Purpose of Insurance*

Personal

Purpose of Insurance*

Income Replacement

Estate Conservation

Other

Please explain*

Existing and Pending Coverages

Do You have any Life coverages in force or pending, including any with RBC Life?*

Yes

Provide details below. Complete Replacement forms where necessary.

1- Name of Insurance Company*

Amount of Life Insurance (including term riders)*

Policy #*

Purpose of Insurance*

Personal

Business

Year and Month Issued*

Is the insurance applied for intended to replace any insurance now in force with any company?*

Yes

2- Name of Insurance Company

Amount of Life Insurance (including term riders)

Policy #

Purpose of Insurance

Personal

Business

Year and Month Issued

Is the insurance applied for intended to replace any insurance now in force with any company?

Yes

3- Name of Insurance Company

Amount of Life Insurance (including term riders)

Policy #

Purpose of Insurance

Personal

Business

Year and Month Issued

Is the insurance applied for intended to replace any insurance now in force with any company?

Yes

4- Name of Insurance Company

Amount of Life Insurance (including term riders)

Policy #

Year and Month Issued

Is the insurance applied for intended to replace any insurance now in force with any company?

Yes

Purpose of Insurance

Personal

Business

Have You applied for life, critical illness or disability insurance concurrently with this Application or within the past 12 months with any other company?*

Yes

Indicate the details

Amount applied for*

Coverage Type*

Life

Name of Insurer*

Amount applied for

Coverage Type

Life

Name of Insurer

Amount applied for

Coverage Type

Life

Name of Insurer

Beneficiary

How many Beneficiaries do you have ?*

Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

2- Full Name of Beneficiary (only complete if multiple beneficiaries)*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

3- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

4- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

5- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

6- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

7- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

8- Full Name of Beneficiary*

Beneficiary type*

Revocable

Irrevocable

Relationship to Proposed Insured (Proposed Owner in Quebec)*

Status*

Share %*

Please enter a number from 0 to 100.

* Total % share must equal 100% for Primary Beneficiaries.

* Total % share must equal 100% for Contingent Beneficiaries.

Proposed Owner(s)

Title*

Mr.

Mrs.

Ms.

Miss

Dr.

First or Company Name*

Middle name

Last name

Relationship to Proposed Insured (if Proposed Insured is not Policy Owner).

Mailing Address

For billing and correspondence

Street*

City*

Province*

Postal Code*

Attention

E-mail Address*

FINANCIAL INFORMATION

What is Your annual earned income from employment in Canadian dollars?*

What is Your estimated net worth in Canadian dollars?*

Amount of mortgage outstanding on personal residence and/or cottage?*

If not self-supporting, what is the annual gross amount of the family earned income?

What is Your annual income in Canadian dollars from other sources?*

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Person A

Describe “other sources” of income*

Describe “other sources” of income

Have You within the past 5 years declared personal or corporate bankruptcy?*

Yes

Provide the discharge date and complete details below.

Discharge Date*

Complete Details*

Additional Information

Have You collected EI (Employment Insurance), disability benefits, workers' compensation benefits, CPP or QPP disability benefits, income replacement benefits, or any form of social assistance in the past 12 months?*

Yes

Provide Details

Date Started

Date Ended

Benefits

Disability

WCB

Other

Please describe other

Have You within the past 24 months been a student pilot, or piloted a plane, ultra-light or glider, or do You have any intention of doing so in the future?*

Yes

Please complete the Aviation Questionnaire. Please contact your YAM Insurance representative for a copy of this questionnaire.

Have You within the past 12 months traveled outside Canada or the United States of America, or do You intend to do so within the next 12 months?*

Yes

Dates*

Countries/Cities*

Length of Stay*

Reason*

Date

Countries/Cities

Length of Stay

Reason

Have You within the past 24 months engaged in any hazardous contact sports or activities, including but not limited to racing, scuba diving deeper than 100ft(30m), skydiving, heli-skiing or back-country skiing, or do You intend to do so?*

Yes

Hazardous Sport or Activity Type*

Dates, Frequency, Professional/Amateur, Recreational/Commercial*

Hazardous Sport or Activity Type

Dates, Frequency, Professional/Amateur, Recreational/Commercial

Hazardous Sport or Activity Type

Dates, Frequency, Professional/Amateur, Recreational/Commercial

Have You ever had life, disability or critical illness insurance rated, modified, rejected, rescinded, or have You been denied renewal or reinstatement?*

Yes

Indicate Type of Insurance*

Status*

Rated

Modified

Rejected

Rescinded

Denied Renewal or Reinstatement

Insurance Company*

Reason*

Indicate Type of Insurance

Status

Rated

Modified

Rejected

Rescinded

Denied Renewal or Reinstatement

Insurance Company

Reason

Indicate Type of Insurance

Status

Rated

Modified

Rejected

Rescinded

Denied Renewal or Reinstatement

Insurance Company

Reason

Indicate Type of Insurance

Status

Rated

Modified

Rejected

Rescinded

Denied Renewal or Reinstatement

Insurance Company

Reason

Have You within the past 10 years been convicted of any criminal offence, or are there any such charges pending?*

Yes

Date of Incident*

DD slash MM slash YYYY

Details Including Outcome*

Date of Incident

DD slash MM slash YYYY

Details Including Outcome

Have You within the past 10 years been convicted of any driving offences or violations, including impaired driving, and/or have You had a driver's license revoked or suspended, or are any such charges pending?*

Yes

Driver’s License Number*

Details, Dates, Offence Type(s), km/h Over Limit*

MEDICAL HISTORY: PROPOSED INSURED (You/Your refers to the Proposed Insured)

When answering the questions on this form, DO NOT provide information about any genetic test you have taken or plan to take. A genetic test is a type of medical test which analyzes DNA, RNA, or chromosomes. DO provide information about other types of medical tests.

Legal Name of Proposed Insured*

Paramedical requested?*

Yes

Medical History

Current Height*

Unit*

ft/in

Current weight*

Unit*

Have You lost 10lb/5kg or more within the past 12 months?*

Yes

Reason*

Amount Lost*

Measure Unit*

Are You presently under medical observation or investigation, treatment, therapy, counselling, or taking medication?*

Yes

Details*

Name of Medication*

Dose Amount*

Frequency Taken*

Date Started*

DD slash MM slash YYYY

Name of Medication

Dose Amount

Frequency Taken

Date Started

DD slash MM slash YYYY

Name of Medication

Dose Amount

Frequency Taken

Date Started

DD slash MM slash YYYY

Have You had any symptoms or complaints regarding Your health for which You have not yet consulted a physician or received treatment?*

Yes

Details*

Conditions, Symptoms, Duration, Results and Treatment

Date of Onset

Name of Healthcare provider

Date of Recovery

Who is Your family physician or regular healthcare provider or clinic?*

Provide the full address and phone number*

Provide the name of the healthcare provider who has Your most recent health record if different from Your regular healthcare provider or clinic.

Provide the name of the healthcare provider who has Your most recent health record if different from Your regular healthcare provider or clinic.

What are the date and reason for Your last consultation with ANY physician or healthcare provider, the name of the provider, and the outcome/results? *

What is the date and reason for Your last consultation with any physician or healthcare provider, the name of the provider, and the outcome/results?*

Was any follow-up, further investigation or referral to another healthcare professional recommended?*

Yes

Details*

Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider, and date of recovery.

MEDICAL DETAILS - PROPOSED INSUREDS

In the past 24 months have You used cigarettes, e-cigarettes, vaping products, cigars, water pipes, betel nut, smoking cessation products or nicotine or tobacco in any form? *

In the past 24 months have You used cigarettes, e-cigarettes, vaping products, cigars, water pipes, betel nut, smoking cessation products or nicotine or tobacco in any form?*

Yes

Product type*

Quantity and Frequency of Use*

Date of last use

DD slash MM slash YYYY

Product type

Quantity and frequency of use

Date of last use

DD slash MM slash YYYY

Product type

Quantity and frequency of use

Date of last use

DD slash MM slash YYYY

Details of Smoking Cessation Therapy (type, when started/completed)

Have You used marijuana and/or hashish within the past 5 years?*

Yes

Indicate the type, quantity and frequency of use, and date last used.*

Do You consume alcoholic beverages?*

Yes

Amount of beer cans/bottles

Frequency

Day

Week

Month

Year

Amount of Wine glasses

Frequency

Day

Week

Month

Year

Amount of Liquor ml/oz

Frequency

Day

Week

Month

Year

Have You ever sought or received advice or treatment relating to alcohol use, or used alcohol excessively?*

Yes

You will need to complete an Alcohol Questionnaire before coverage can be issued. Please contact your YAM Insurance representative for a copy of this questionnaire.

Have You ever used cocaine, barbiturates, crack, or any other narcotic drug, or ever sought or received advice or treatment for the use of drugs, prescribed or non-prescribed?*

Yes

Indicate the type of drug, quantity and frequency of use, and date last used.*

Have You ever had any known indication of or been treated for acquired immune deficiency syndrome, AIDS related complex, AIDS related conditions, or have You tested positive for antibodies to the AIDS virus or HIV?*

Yes

Details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for any disease or disorder of the eyes, ears, nose or throat (including loss of speech)?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for sleep apnea, chronic insomnia, or any other sleep disorder?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for cholesterol, peripheral vascular disease or any disease or disorder of the heart or circulatory system?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for stroke, transient ischemic attack (TIA), headaches, cognitive impairment, memory disorder, Parkinson's disease, Alzheimer's disease, motor neuron disease, Huntington's disease, fainting spells, dizziness, seizures, epilepsy, paralysis, multiple sclerosis, muscle weakness, numbness or tingling of the limbs, or any disease or disorder of the brain or nervous system?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for any disease or disorder of the kidneys, urinary tract, bladder, prostate, or genital organs, or kidney stones, or albumin, blood, or sugar in the urine?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for anxiety, depression, nervousness, stress, fatigue, burnout, eating disorder, other emotional disorder, psychiatric disorder, mental disorder or psychosis; or ever attempted suicide?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Date of Recovery

DD slash MM slash YYYY

Name of Healthcare Provider

Have You ever had any known indication of or been treated for chronic fatigue, chronic fatigue syndrome, Epstein-Barr virus, fibromyalgia, or chronic pain?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for cancer, dysplastic nevi, tumour, cyst, mass, lesion, lump, nodule, polyp or other growth, any disorder of the skin or lymph glands, blood disorder or any form of malignant disease?*

Yes

Indicate the details*

Details may include conditions, symptoms, duration, results, treatment, date of onset, name of healthcare provider, and date of recovery.

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for diabetes, endocrine disorder, elevated blood sugar, thyroid disease, rheumatism, rheumatic fever, lupus, gout, or syphilis?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for any disease or disorder of the reproductive organs or breast including lumps, cysts or other masses, other physical changes, abnormal mammogram findings or any biopsy?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for any amputation or deformity, hernia or rupture, deep vein thrombosis or varicose veins?*

Yes

Indicate the details*

Date of Onset

DD slash MM slash YYYY

Name of Healthcare Provider

Date of Recovery

DD slash MM slash YYYY

Have You ever had any known indication of or been treated for any arthritis, disease or disorder of the muscles, bones, hip, ankle, knee, wrist, elbow, shoulder, hands, feet or any other joint?*

Yes

Indicate the details*

Have You ever had any known indication of or been treated for any type of back or spinal trouble including sprain, strain, or disc disease or disorder?*

Yes

Indicate the details*

Have You ever had any known indication of or been treated for any type of shortness of breath, persistent cough, asthma, emphysema, bronchitis, pleurisy, tuberculosis, or any disease or disorder of the chest or lungs?*

Yes

Indicate the details*

Have You ever had any known indication of or been treated for any type of peptic ulcer, indigestion, colitis, or any disease or disorder of the stomach, colon or intestines, gall bladder, liver, pancreas; or have You tested positive for hepatitis and/or been told You are a carrier?*

Yes

Indicate the details*

Have You in the past 10 years been examined by or consulted a physician, chiropractor, psychologist, physiotherapist, osteopath, homeopath, or other practitioner?*

Yes

Indicate the details*

Have You in the past 10 years been under observation or treatment in any hospital or other institution or facility, or been advised to be admitted?*

Yes

Indicate the details*

Have You in the past 10 years had an X-ray, ECG, CT scan, MRI, blood or urine test, abnormal PSA (Prostate Specific Antigen) test, or other diagnostic tests?*

Yes

Indicate the details*

Have You in the past 10 years been advised to have any diagnostic test, be hospitalized, or have surgery which was not completed?*

Yes

Indicate the details*

Have Your natural parents, brothers, or sisters, either living or dead, ever suffered from any of the following conditions: heart disease, polycystic kidney disease, high blood pressure, a stroke, diabetes, cancer, multiple sclerosis, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, motor neuron disease or any form of hereditary disease?*

Yes

Condition*

Mother*

Yes

Father*

Yes

Sister*

Yes

Brother*

Yes

Mother's age at Onset*

Father's age at Onset*

Sister's age at Onset*

Brother's age at Onset*

2. Condition

Mother

Yes

Father

Yes

Sister

Yes

Brother

Yes

Mother's age at Onset

Father's age at Onset

Sister's age at Onset

Brother's age at Onset

3. Condition

Mother

Yes

Father

Yes

Sister

Yes

Brother

Yes

Mother's age at Onset

Father's age at Onset

Sister's age at Onset

Brother's age at Onset

4. Condition

Mother

Yes

Father

Yes

Sister

Yes

Brother

Yes

Mother's age at Onset

Father's age at Onset

Sister's age at Onset

Brother's age at Onset

For Female Applicants Only

Have You ever had a miscarriage or other complication of pregnancy?*

Yes

Details*

Are You pregnant?*

Yes

Give due date*

DD slash MM slash YYYY

TEMPORARY LIFE INSURANCE APPLICATION

If any of the following questions are answered “Yes,” or left blank and/or if any Proposed Insured is under 15 days of age or over 65 years of age, the Proposed Insured(s) is not eligible to apply for Temporary Life Insurance. When answering the questions on this form, please do so without reference to any genetic tests you may have taken or are planning to take. A genetic test is a type of medical test which analyzes DNA, RNA, or chromosomes.

1. Has the Proposed Insured ever been treated for or had any indication of heart or circulatory disease, heart attack, high blood pressure, chest pain, abnormal ECG, stroke, transient ischemic attacks (TIAs), diabetes, chronic kidney, liver, or lung disease, cancer or tumour, multiple sclerosis, paralysis, motor neuron disease, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, AIDS, ARC or HIV infection, loss of speech, blindness or deafness?*

Yes

2. Has the Proposed Insured within the past year, other than normal childbirth, been admitted to a hospital or other medical facility or been advised to do so?*

Yes

3. Has the Proposed Insured been advised to have any tests, investigations or surgery not yet done?*

Yes

4. Has the Proposed Insured in the past year had any Application for life insurance, change or reinstatement declined, rated or modified in any way?*

Yes

5. Is the Proposed Insured aware of any symptoms for which they have not sought treatment or for which treatment is planned or pending?*

Yes

PART 1: PERSONAL AND EMPLOYMENT INFORMATION (You/Your refers to the Proposed Insured)

PROPOSED INSURED

Print name as legally known:

Home Address:

Business/Employer

Main Purpose of Insurance

Existing and Pending Coverages

Beneficiary

Proposed Owner(s)

Mailing Address

FINANCIAL INFORMATION

Additional Information

MEDICAL HISTORY: PROPOSED INSURED (You/Your refers to the Proposed Insured)

Medical History

MEDICAL DETAILS - PROPOSED INSUREDS

For Female Applicants Only

TEMPORARY LIFE INSURANCE APPLICATION

PART 1: PERSONAL AND EMPLOYMENT INFORMATION
(You/Your refers to the Proposed Insured)