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RBC Application

Step 1 of 5

20%

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Email
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Spouse Email
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First Name
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Spouse First Name
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Last Name
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Spouse Last Name
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Tag 1
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Tag 2
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Main Form ID
Information About (You)
Full Address*
Address Apt No (optional) City State / Province / Region ZIP / Postal Code Country
Mailing Address
- Same as Above
Mailing Address*
Address Apt No (optional) City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Identification
Identification*
Province/Territory of Issue*
Number*
Expiry Date*
MM slash DD slash YYYY

Birthplace and Citizenship for (You)
Country of Birth*
Residency Status*
- Canadian Citizen
- Permanent Resident
- Other
Have you been residing in Canada for less than 12 months?*
- Yes
- No
Please Specify*
Purpose of Insurance for (You)
What is the purpose of insurance?*
- Income Replacement
- Estate Preservation
- Mortgage and Debt Protection
- Other
Please Specify
Existing/Pending Coverages for (You)
Do you have any have any Life, Critical Illness or Disability Insurance coverages in force or pending, including with RBC?*
- Yes
- No
Will you be cancelling any existing life insurance if this application is approved?
- Yes
- No
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Have you ever been declined for insurance?
- Yes
- No

Beneficiary`s for (You)
Primary Beneficiary(s)
Full Name*

Date of Birth*

Gender*

Relationship*

Please specify

Share %*

Would you like to be able to change the beneficiary without having his/her consent?*
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Benficiary Full Name
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Benficiary Date of Birth
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Benficiary Gender
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Benficiary Relationship
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Benficiary Specify
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Benfeficiary Share
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Benfeficiary Consent
Contingent Beneficiary(s)
Would you like to add a Contingent Beneficiary to this coverage?*
- Yes
- No
Full Name*

Date of Birth*

Gender*

Relationship*

Please specify

Share %*
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Contingent Full Name
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Contingent Gender
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Contingent Relationship
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Contingent Specify
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Contingent Share
Trustee for All Minor Beneficiaries
Are any primary or contingent beneficiaries a minor?*
- Yes
- No
Full Name*

Financial Information for (You)
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Are you employed?
- Yes
- No
Details
Occupation*
Name of Employer*
Address*
Nature of Business*
Length of Time with the Employer*
Description of Duties*
What is your occupation?
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Section Break
What Is Your Occupation?*
Annual Earned Income ($)*
Canadian Net Worth ($)*
Foreign Net Worth ($)*
Have you declared personal or corporate bankruptcy that has not been discharged?*
- Yes
- No
Discharge Month and Year*

Billing For (You)
Providing your bank info today will not result in a payment being withdrawn. You may cancel your policy at any time without any penalty. If the policy is not approved for any reason no charges will be made to your bank account.
Name of Account Holder*
Branch no.*
Institution no.*
Account no.*
Name of Financial Institution*
Is there a preferred day to pay the monthly premium?
How did you hear about us?
Other
*
- I agree to the Client Disclosure terms.

Terms of Use
Privacy Policy

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Affinity Life Inc., is an insurance brokerage licensed to sell life insurance products in Alberta and British Columbia. We are currently not available in other provinces. Policy obligations are the sole responsibility of the issuing insurance company. Coverage is subject to underwriting by the selected insurance company. Please see policy documents for full terms, conditions, and exclusions. The logos and trademarks used here are owned by the respective entities. Refer to our Privacy Policy and Terms of Use for additional information.

Terms of Use
Privacy Policy

Facebook-f Instagram Youtube Linkedin-in

Affinity Life Inc. is an insurance marketing agency that provides insurance products through a network of affiliated, licensed insurance agents across Canada. Policy obligations are the responsibility of the broker and the issuing insurance company. Coverage is subject to underwriting by the selected insurance company. Please see policy documents for full terms, conditions, and exclusions. The logos and trademarks used here are owned by the respective entities. Refer to our Privacy Policy and Terms of Use for additional information.