Group Insurance Application

Transcription

1 Group Insurance Application This Application is a legal document which will form part of the Group Policy Print legibly in black ink. Corrections must be initialed. After the Application has been signed, all additions, deletions and changes must be initialed by the Applicant. A facsimile of the completed, signed Application will be accepted in the preliminary stages of the group issue process. The signed original Application must be received by RBC Insurance Head Office before any policy or Employee booklet is released, and in no event later than 60 days following the Group Policy effective date.

2 Your Privacy Matters To Us At RBC Life Insurance Company (RBC Insurance), we re committed to protecting your privacy. We respect your privacy and want you to understand how we safeguard personal information. How we collect your information We collect and keep information about your company and your Employees which is needed to provide the products and services you request. We collect information from you, either directly or through our representatives. We may also need to collect information about you from sources such as other insurers, doctors and other health care providers, the government and governmental agencies and from you, the Employer. How we use information We use this information to provide the products and services you request, which includes using it to evaluate insurance risk, manage claims and administer the insurance. We may also share your information with others who work for RBC Insurance or other RBC Financial Group companies, or with third parties, when it is necessary for the services we provide. Third parties may include other insurance companies, the government and governmental agencies and the Employer. Health information is not shared without the insured s consent. We may use this information internally, to prepare statistical reports that help us understand the needs of our customers and that help us understand and manage our business. Social Insurance Numbers will be used for identification purposes if the individual has given us permission to do so, and will be used for taxation purposes when necessary. Other ways we use your information When you request products and services directly from RBC Insurance, there are other ways we may use your information. For example, we may use or share information to help you and/or your Employees find out about other products and services from RBC Insurance and other RBC Financial Group companies. However, we will never use or share health information for these purposes. To better manage your relationship with other members of RBC Financial Group, and where the law allows us, we may consolidate the information we have about you and/or your Employees with information held by the other companies. If, at any time, you decide that you do not want us to use your information as described here, under Other ways we may use your information, please let us know by calling us at Accessing Information Your Employees have a right to access the personal information that we have about them in our files. If we have information that is not correct, you can have it corrected. To access information or to ask us to correct information, Employees can contact us at: RBC Life Insurance Company P.O. Box 5044, Burlington, ON L7R 4C1 Telephone: Facsimile: If you would like more information about client privacy RBC Financial Group publishes a brochure on client privacy. If you would like a copy of the brochure, please contact us at the above number.

3 GROUP INSURANCE APPLICATION All questions must be answered in full 1. Full Legal Name of Employer: (include both upper and lower case, if applicable.) 2. Address (Head Office): City: Province: Postal Code: 3. Legal Status of Employer: Corporation Partnership Sole Proprietor Association, Society or Trust (Please attach Association Questionnaire) Other (Specify): 4. Nature of Business: 5. Name of Authorized P( lan Administrator : Title: Telephone Number: ( ) Fax: ( ) address: 6. Billing Method: Insurer Administered iservices Self-Administered Third-Party Administered (Please attach TPA Appointment & TPA Questionnaire to Client Information Questionnaire) Additional comments if required: 7. Coverage: Continuity of Applying for: coverage required Name of Current Insurer: from Current Insurer: Basic Life Basic AD&D Dependent Life Voluntary Life Short Term Disability Long Term Disability Date current coverage terminates: (D/M/Y) NOTE: Current coverage should not be cancelled until written confirmation by RBC Insurance of acceptance of this Application has been provided. Is the Group Coverage noted above being applied for in conjunction with any individual RBC Insurance product? Yes No 8. Requested Effective Date of RBC Insurance Group P( olicy: (D/M/Y) 9. Eligibility: A person must be a permanent Employee, partner or proprietor who is in active employment in Canada and performing or scheduled to perform all the material and substantial duties of the person s regular occupation for at least the minimum hours per week, each week. Eligible Employees will not include seasonal Employees, contract Employees, foreign nationals or independent contractors unless written pre-approval has been given by RBC Insurance. For Canadian and Foreign National contract Employees, a completed Contract Employee Questionnaire must be attached to this Application. Minimum number of hours for eligibility: / week (30 hours/week is standard) Current number of: Eligible Employees Participating Employees

4 10. Are any Employees to be insured members of a Union? Yes No Does the Applicant expect to match group policy provisions with a collective agreement? Yes* No *If Yes, please attach a copy of the current collective bargaining agreement. Note: unless otherwise approved in writing, RBC Insurance will not be bound by any union arbitration decision or collective bargaining agreement. 11. Class Descriptions: Class 1 Class 2 Class Waiting P( eriod: An Employee is to be insured on (please check the appropriate box): The completion of continuous, active eligible employment, or The date the Employee commences active eligible employment or on the policy effective date, or The first of the month coincident with or next following of continuous, active eligible employment. (If the waiting period differs by class, please indicate on a separate sheet.) Does the waiting period apply to Employees who have not completed it with the current carrier? Yes - all current Employees must satisfy any remainder. No - all current Employees will be covered on the policy effective date. 13. P( articipation: Basic Life and AD&D Mandatory Non Mandatory (minimum 75% participation required) Long Term Disability Mandatory Non Mandatory (minimum 75% participation required) Short Term Disability Mandatory Non Mandatory (minimum 75% participation required) 14. On the date of this Application, are there any Employees not actively at work due to illness or injury? Yes No If Yes, provide details: Employee Name Employee Name Date of Birth Date of Birth Gender Gender Date of Illness/Injury Province of Residence Date of Absence Prognosis Nature of Absence Expected Date of Return On the date of this Application, are there any Employees not actively at work due to maternity / parental leave, layoff or other approved leave? Yes No If Yes, provide details: Expected Date of Return Life Waiver of Premium Approved Yes No Yes No Yes No Group Insurance Remains in Force Yes No Yes No Yes No 15. Definition of Earnings Eligible Classes Salary Only Salary and Commission Salary, Commission and Bonus (attach completed Bonus Questionnaire) T-4 Employment Income ( Calendar year Tax year) Commission included Yes No Bonus Included Yes No (attach Bonus Questionnaire if applicable) T-5013 SUM/Partnership Schedule Summary ( Calendar year Tax year) T-1 Partnership Schedule ( Calendar year Tax year) Other (specify) NOTE: If commissions are included, this does not include renewal commissions. If bonus and/or commission are included, these must always be reflected in the earnings reported to RBC Insurance for each Employee.

5 Basic Life: GROUP LIFE INSURANCE Attached to and forming part of the Application for Group Insurance to be Underwritten by RBC Life Insurance Company Class Class Class Benefit Schedule Percentage of Annual Earnings % % % or Flat Amount $ $ $ Maximum $ $ $ P( remium Contribution % Employer % Employee NOTE: If split by division or class please indicate under Comments. Reduction and Termination: Reduces 50% at age 65 and terminates upon the Employee attainment of age 70 or earlier retirement. Comments: Dependent Life: Amounts: Spouse: $ (Limited to lesser of 100% of the Employee amount or $ 25,000) Child(ren) $ (Limited to lesser of 50% of the Employee amount or $ 10,000) Definition of Dependent Child: Standard with Student age limit (24 hours to 21 years, or 25 years if full time student) Other (May be subject to Underwriting Approval) P( remium Contribution Split: % Employer % Employee NOTE: If split by division or class please indicate under Comments. Termination: Employee attainment of age 70 or earlier retirement. Comments:

6 Voluntary Life: Amounts: Employee: Units of $ 10,000 to a maximum of $. (NOTE: Maximum cannot exceed $ 250,000.) Spouse: Units of $ 5,000 to a maximum of $. (NOTE: Spouse voluntary life is subject to a maximum of 100% of the Employee amount.) Each Child: Units of $ 2,000 to a maximum of $. (NOTE: Child voluntary life is subject to a maximum of the lesser of 50% of the Employee amount or $ 10,000.) P( remium Contribution Split: % Employer % Employee NOTE: If split by division or class please indicate under Comments. Termination: Employee attainment of age 70 or earlier retirement. NOTE: Basic Life Must be taken in order to apply for Voluntary Life Comments:

7 P( rincipal Sum (Flat amount or Multiple earnings) P( lan Maximum ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Attached to and forming part of the Application for Group Insurance to be Underwritten by RBC Life Insurance Company Class Class Class Additional P( lan Features Available (costing required) Burn Benefit Yes Yes Yes Comatose Benefit (maximum $500,000) Contagious Disease Benefit (maximum $250,000) Education Benefit (maximum 5% per year up to 4 years) Family Transportation Benefit (maximum #5,000 or $10,000) Felonious Assault Benefit (maximum: lesser of 10% or $10,000) Funeral Expense Benefit (maximum $3,000) HIV Adjustment Benefit (lump sum $ 25,000) Kidnap and Extortion Benefit (maximum: lesser of 10% or $10,000) P( arental Care Benefit (maximum: lesser of 10% or $10,000) P( ermanent and Total Disability Benefit (maximum $500,000 - lump sum) Rehabilitation P( hysical Therapy Benefit (maximum: lesser of 10% or $10,000) Repatriation/Identification Benefit (maximum $10,000) Yes Yes Yes Yes Yes Yes Yes Yes Yes $5,000 $10,000 $5,000 $10,000 $5,000 $10,000 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Seat Belt Benefit (maximum 10%) Yes Yes Yes Seat Belt/Air Bag Benefit (maximum seat belt 10% and air bag #5,000) P( remium Contribution: % Employer % Employee NOTE: If split by division or class please indicate under Comments. Yes Yes Yes Reduction: same as Group Basic Life other (specify): Termination: Employee attainment of age 70 or earlier retirement. Comments:

8 SHORT TERM DISABILITY (STD) INSURANCE Attached to and forming part of the Application for Group Insurance to be Underwritten by RBC Life Insurance Company Is the STD P( lan intended to qualify for EI P( remium Reduction P( rogram? Yes No Class Class Class Weekly Benefit % of weekly earnings OR flat $ % of weekly earnings OR flat $ % of weekly earnings OR flat $ Maximum Benefit per week. equal to maximum EI benefit, adjusted annually. per week. equal to maximum EI benefit, adjusted annually. per week. equal to maximum EI benefit, adjusted annually. Elimination P( eriod - Injury Days Days Days - Illness Days Days Days - Days of hospitalization Includes day surgery Days Days Days Yes No Yes No Yes No Maximum Benefit (17, 26 and 52 weeks) Weeks Weeks Weeks Elimination P( eriod and Benefit Based on Calendar Days (1/7 th ) or Working Days (1/5 th ) Calendar Days Working Days Calendar Days Working Days Calendar Days Working Days Residual Benefit NOTE: If Residual LTD is included, STD Residual MUST be selected. Yes No Yes No Yes No P( remium Contribution: % Employer % Employee NOTE: If split by division or class please indicate under Comments. Termination (check one): Employee attainment of age 70 or earlier retirement. Employee attainment of age 65 or earlier retirement. Comments:

9 LONG TERM DISABILITY (LTD) INSURANCE Attached to and forming part of the Application for Group Insurance to be Underwritten by RBC Life Insurance Company If more than 3 classes, please attach second sheet. Class Class Class P( ercentage of Monthly Earnings (NOTE: 66 2/3% = %) % % % Single Split If Split, 1 st level Of the 1 st $ of Monthly Earnings Of the 1 st $ of Monthly Earnings Of the 1 st $ of Monthly Earnings Double Split If Double Split, next level Triple Split Final Level % of the next $ of Monthly Earnings OR remainder % of the remainder of Monthly Earnings % of the next $ of Monthly Earnings OR remainder % of the remainder of Monthly Earnings Non Evidence Maximum $ $ $ % of the next $ of Monthly Earnings OR remainder % of the remainder of Monthly Earnings Maximum Benefit or Flat Amount Gainful Occupation (Definition based on gross disability payment is not available with reverse combo plans) Elimination P( eriod (in days) CP( P( /Q: P( P( Offsets (Primary or Secondary) All Source Maximum (Standard is 85%) Benefit Duration (Standard is to age 65) $ $ $ % of indexed monthly earnings gross disability payment % of indexed monthly earnings gross disability payment % of indexed monthly earnings gross disability payment P( re-existing Conditions Exclusion Definition of Disability Own Occupation P( eriod months months months (P( artial requires Total Disability throughout the Elimination Period) (Residual does not require Total Disability throughout the Elimination Period. Partial or Residual Partial or Residual Partial or Residual

10 Additional P( lan Features Available (costing required) Class Class Class Survivor Benefit (3 months is standard) 24 Months 24 Months 24 Months Spouse Disability ($1,000, $1,500, $2,000, $2,500 or $3,000 per month - Standard is $1,000) Spouse Disability Duration (24 or 36 months - Standard duration is 24 months) $ 24 Months 36 Months $ 24 Months 36 Months $ 24 Months 36 Months Disability P( lus (25% or 30%) NOTE: If 25% is selected, All Source Maximum is 75%. If 30% is selected All Source is 70%. 25% 30% Maximum Benefit 25% 30% Maximum Benefit 25% 30% Maximum Benefit $ $ $ Critical Illness 5X LTD benefit to $25,000 10X LTD benefit to $50,000 5X LTD benefit to $25,000 10X LTD benefit to $50,000 5X LTD benefit to $25,000 10X LTD benefit to $50,000 Cost of Living Adjustment COLA P( ercentage (1%, 2%, or 3%, or lesser of ½ CPI and 3%) Flat % OR lesser of 3% or ½ CPI Flat % OR lesser of 3% or ½ CPI Flat % OR lesser of 3% or ½ CPI COLA Duration (5 or 10 years or to age 65) COLA Deferral (1, 2, 3, 4, or 5 yr) yr yr Conversion Yes Yes Yes Education Benefit (per month) Recovery Income P( rotection (up to 4 months duration) Extended Recurrent Disability Benefit - (Extends coverage for up to 12 months with new Employer for recurrent disability) $200 $400 $200 $400 yr $200 $400 Yes Yes Yes Yes Yes Yes Retirement Income P( rotection Benefit - Percentage - (1% to 15%) % % % Revenue P( rotection (10% to 60% - increments of 10%)) % % % Duration months months months

11 Group Long Term Disability P( remium Contribution Split: % Employer % Employee IMP( ORTANT i) The Applicant acknowledges and agrees that the premium contribution split directly affects the Taxable / Non Taxable status of the LTD benefit. Should the above information concerning the premium split be inaccurate, or should any subsequent change in contribution split occur, the Applicant is responsible for notifying RBC Insurance in writing, in a timely manner. In determining the taxability of LTD benefits under the policy specifically, whether to issue tax slips for LTD benefits paid, RBC Insurance shall be entitled to rely upon the information provided in writing by the Applicant, and the Applicant agrees to hold harmless RBC Insurance with respect to the consequences of any benefits paid to a claimant on an incorrect taxable or non taxable basis. ii) If split by division or class, please indicate under Comments. Termination: Long Term Disability Insurance terminates upon the Employee attainment of age 65 or earlier retirement. Is the Long Term Disability Plan being sold as a Combination plan which will be integrated with Guaranteed Standard Issue Individual Disability? (If yes, please include a signed offer letter.) Yes No Comments:

12 LONG TERM DISABILITY (LTD) INSURANCE For Groups 2 to 9 Lives Attached to and forming part of the Application for Group Insurance to be Underwritten by RBC Life Insurance Company Plan Features indicated by an asterix (*) are Standard, with no option available Eligibility * All active full-time Employees under age 65 Benefit * 66 2/3% with an 85% all source maximum Maximum Benefit $3,000 $4,000 Elimination P( eriod * 120 days Accumulation P( eriod * CP( P( / Q: P( P( Offset * Cost of Living Freeze * Benefit P( eriod * To age 65 P( re-existing Conditions Exclusion * 24/12 Own Occupation P( eriod * Definition of Disability (P( artial requires Total Disability throughout the Elimination Period. 30 days accumulation period Family (Indirect) with 85% All Source Yes 2 year own occupation period check one only: Partial Residual does not require Total Disability throughout the Elimination Period) Gainful Occupation Definition of Earnings Survivor Benefit (with Accelerated feature) * Conversion * Waiver of P( remium * Recurrent Disability * Work Incentive Benefit * Continuity of Coverage * Dependent Care Expense Benefit * Rehabilitation and Return to Work Benefit * Total Benefit Cap * Services * Residual 80% if working; 60% if not working Gross Payment Sole Proprietor Partner T-1 T-4 Partner T months Yes Yes 6 months Yes Yes Yes Yes Yes - Work-Life Employee Assistance Program - Best Doctors fi - WorkRx Essential Group Long Term Disability P( remium Contribution Split: % Employer % Employee IMP( ORTANT NOTE: The Applicant acknowledges and agrees that the premium contribution split directly affects the Taxable / Non Taxable status of the LTD benefit. Should the above information concerning the premium split be inaccurate, or should any subsequent change in contribution split occur, the Applicant is responsible for notifying RBC Insurance in writing, in a timely manner. In determining the taxability of LTD benefits under the policy specifically, whether to issue tax slips for LTD benefits paid, RBC Insurance shall be entitled to rely upon the information provided in writing by the Applicant, and the Applicant agrees to hold harmless RBC Insurance with respect to the consequences of any benefits paid to a claimant on an incorrect taxable or non taxable basis. Termination: terminates when the Employee attains age 65 or at such earlier date as may be provided by the terms of a policy. Comments:

13 BONUS QUESTIONNAIRE For Groups 2 to 9 Lives Attached to and forming part of the Application for Group Insurance NOTE: Including bonuses in the basic monthly earnings definition is subject to Underwriting approval. Full Legal Name of Employer: If bonuses are to be included in earnings, please complete the following questions: 1. Who is eligible for the bonus? (List job description, class and/or division) 2. Are disabled Employees eligible? Yes No If Yes, only in a year in which they work? Yes No 3. Bonuses are based on the performance of : the company the individual the company and the individual 4. Are bonuses based on a pre-determined formula? Yes No 5. Are bonuses paid on a standard 12-month basis or a 24-month rolling average basis? 12 months 24 months 6. Are bonuses expected to continue? Yes No 7. How long has the bonus plan been in effect? 8. How many times has the bonus been paid?

14 APPLICANT STATEMENT The Applicant appoints as Agent(s) of Record to act on behalf of the Applicant, and authorizes RBC Insurance to provide said Agent(s) with any information regarding this Group Insurance Application. The Applicant hereby declares that all statements and answers made in this Application including any attachments are full, complete and true as of the date this Application is signed. The Applicant understands and agrees that: 1. This Application, including all attachments, Employee enrollment cards (if any), census listings (if any) and any other documents required by RBC Insurance will form part of the group policy. 2. Coverage for any person will not commence or become effective until the person is a permanent Employee, in Active Employment, and performing all Material and Substantial Duties. 3. Acceptance of the Premium Deposit cheque of $ will not in itself constitute approval of this Application. If the Application is not approved, the Premium Deposit will be returned. 4. Any Group Policy issued from this Application will include and be subject to all of its terms and conditions, which are not set out in full in this Application. 5. The following Group Insurance coverages are attached: Basic, Dependent and Voluntary Life Basic AD&D Short Term Disability Long Term Disability 6. If any Employees are resident in Ontario, the applicable Ontario Retail Sales Tax form is attached: Ontario Retail Sales Tax Remittance Authorization Form Ontario Retail Sales Tax Purchase Exemption Certificate Name and Title of person authorized to sign for the Applicant (PLEASE PRINT) Authorized Person s Signature Signature of Witness if not signed under seal Signed at Dated

15 AGENT OF RECORD STATEMENT 1. Name of Agent of Record: 2. Address: City: Province: Postal Code: Telephone: ( ) - Fax: ( ) Is there currently a Producer Contract in place with RBC Insurance? Yes No 4. Is this the first case with RBC Insurance. (If yes, contracting information will follow.) Yes No Group Application Checklist P( remium Deposit Cheque - in the amount of $ (please provide details if this amount is to be allocated by division). Employee Census Listing - Including Name, Occupation, Date of Birth, Province, Gender, Monthly Earnings, Date of Hire, Hours worked per week, and Employee class and division, if applicable. Employee Enrollment Cards - mandatory if Life Benefit has been sold to identify beneficiary designations. Total cards enclosed: Number of cards still to be submitted: Refusal of Coverage Forms - if applicable. Current Collective Bargaining Agreement - if applicable. Third P( arty Administration (TP( A) Q: uestionnaire - if applicable. Third P( arty Administration (TP( A) Confirmation of Appointment - if applicable. Copy of Offer Letter of Individual Insurance - if Group Insurance is applied for in conjunction with an Individual Insurance product. Copy of most recent billing from current carrier - Required only for previously insured groups. Copy of policy or booklet from current carrier (policy preferred) - Required only for previously insured groups. Client Information Q: uestionnaire Bonus Q: uestionnaire - if applicable. P( lease note: The Group P( olicy Issue process will commence when all required information is received. COMMENTS: I hereby confirm that I have a current and valid licence to sell this insurance in the Province or Territory of, where the sale and negotiation of the insurance being applied for with this application took place. I further confirm that I have fully complied with my duties and obligations in respect of ADVISOR DISCLOSURE, including providing a written Advisor Disclosure Statement to the Applicant. Date Signature of Agent of Record Signature of Witness if not signed under seal

16 ONTARIO RETAIL SALES TAX REMITTANCE AUTHORIZATION

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18 ASSOCIATION, SOCIETY or TRUST QUESTIONNAIRE Attached to and forming part of the Application for Insurance These questions require answers in order for the Policy to be issued to the correct legal entity and to ensure the correct contractual language is used. 1. Is this a true and bona fide Association, Society or Trust? 2. Can this Association, Society or Trust legally broker for insurance for the participating Employers and/or Employees? 3. Who is the Policyholder? 4. Who is (are) the Employer(s)? 5. What is the nature of the relationship between the Policyholder and the individuals insured? 6. Will each Employer be signing a participation agreement to join the Association, Society or Trust? 7. Is there an overall participation requirement of participating Employers? Is there a separate Employee participation level per participating Employer? 8. Will the Policy cover Employees of the participating member Employer? 9. Will Evidence of Insurability be required for the Employees of any participating Employer? 10. Will the Policy cover Employees of the Association, Society or Trust itself? 11. Can individuals be members of this Association, Society or Trust? If so, who will be covered? 12. Do members have to be members of the Association, Society or Trust in good standing with all dues paid to date to be eligible for insurance? Are Associate Members to be covered? 13. Will the Association, Society or Trust make the choices of the benefits or will the participating Employer choose what benefits to offer to Employees? 14. If there are different benefit levels, does the participating Employer/Employee have to remain insured under one level for a certain period of time before being allowed to change to a higher/lower level? 15. Are certain benefits mandatory (core benefits) and others non-mandatory? Is having a non-mandatory benefit contingent on having a core benefit? 16. From whom does RBC Insurance collect the premium - the Association, Society or Trust or each participating Employer?

19 ASSOCIATION, SOCIETY or TRUST QUESTIONNAIRE (cont d) Attached to and forming part of the Application for Insurance These questions require answers in order for the Policy to be issued to the correct legal entity and to ensure the correct contractual language is used. 17. Is each participating Employer to be set up as a separate Billing Division? 18. What is the Grace Period for this group? 19. Where does RBC Insurance go to collect the information on individual Employees - the Association, Society or Trust, or the participating Employer? 20. Who pays the cost of insurance - the Association, Society or Trust, the participating Employer or Employees? (This will effect taxability.) 21. What differs, if anything, between the participating Employers (for example: eligibility, waiting period, minimum number of hours)? 22. Is there an overall waiting period that the Employer must participate in the Association, Society or Trust before becoming eligible?

20 CONTRACT EMPLOYEE QUESTIONNAIRE CANADIAN CONTRACT EMPLOYEE and/or FOREIGN CONTRACT EMPLOYEE This Questionnaire must be completed for each Local Contract Employee and/or Foreign Contract Employee working for the Employer in Canada, for whom group insurance is being applied. Head Office Group Underwriting written pre-approval is required in all cases and will be based on the information provided. Additional documents may be requested, as required. Name of Employer: Group Policy Number: Name of Employee: Occupation: Annual Salary: $ If Canadian Contract Employee, check here and indicate: Start Date of Contract: End Date of Contract: (Day/Month/Year) (Day/Month/Year) OR If Foreign Contract Employee, check here and indicate: Citizenship: Date of Work Permit: Start Date: End Date: (Day/Month/Year) (Day/Month/Year) What benefits is the Employer requesting for this Employee? The Contract Employee is to be insured in accordance with Class of the group policy(ies). Note: It is understood and agreed that the Contract Employee will be eligible for the same coverage afforded any other permanent full-time Employee insured under the group policy(ies) in the same classification of Employees. Such coverage will be subject to all terms and conditions of the policy(ies), as well as the current Group Underwriting guidelines with respect to Contract Employees. Extension of coverage will be considered based on the following information (all questions must be answered): a) Is there a normal Employer / Employee relationship? If no, please explain: b) Does the Employer provide work space for the Employee at the Employer s usual work site? c) Does the Employee perform the usual duties as any other Employee in a similar position? d) Is the Employee working exclusively for the Employer? e) Is the Employee given a T4 by the Employer? f) Is the Employee working full time, as defined in the group policy? g) Is the Employee applying for any other group benefits not insured by RBC Insurance? h) Does the Employer pay CPP/QPP, EI and WCB/WSIB premiums for the Employee? YES NO Employer s Authorized Signature: Date: Name and Title (please print): FOR RBC INSURANCE USE: Group Underwriter Approved: Declined: Date: (Signed by Underwriter)

21 THIRD PARTY ADMINISTRATOR QUESTIONNAIRE Attached to and forming part of the Client Information Questionnaire Required only for groups being administered by a Third Party Administrator (TPA) Administration Fee and Compensation Agreement Name of Policyholder: RATE AND FEE STRUCTURE: 1. Gross Billing Rate to Policyholder: 2. Commission Schedule - check (4) the applicable: A. RBC Insurance Pays The Commissions: Standard Schedule Flat: % Net of Commissions OR B. Commission withheld by TPA (net remit) - Flat: % 3. Administration Fees: 4. Enrollment Fees: 5. Association Fees/Dues: 6. RBC Insurance s Net Rates: Name of the TPA: Contact Name: Address: Telephone: ( ) Fax: ( ) Name of Broker (P( LEASE P( RINT) Broker s Signature Date Signed

22 Registered trademarks of Royal Bank of Canada. RBC Insurance is a registered trademark of Royal Bank of Canada. Used under license (REV. 06/2006)