facsimile - RBC Insurance

FACSIMILE
RBC Life Insurance Company
P.O. Box 515, Station “A”
Mississauga, ON L5A 4M3
Date:
______________________________
To:
LabOne
Re:
Telephone Application Process
Fax #: 1-800-235-2098
Tel: 1-888-881-7712
# Of Pages (including cover sheet): ________
Proposed Insured’s Name: _______________________________________________
Application Serial #:
___________________ Agency: _____________________
Representative’s Name:
____________________________
Code: __________
Representative’s Telephone Number: _______________________________________
Please indicate the product type:
Destiny®
T10
T20
> Destiny - Face amounts of $250, 001 and up for ages 41 and above
Face amounts of $500, 001 and up for ages 0-40
> Term 10 & 20 – All face amounts
Please indicate the service company you wish to use for the following:
Fluid Collection, tests and medicals
Hooper Holmes/Portamedic
Bodimetrics/Quality Underwriting
Medisys
Medifast
ExamOne
No Preference
Inspection Reports
First Financial
Hooper Holmes/Portamedic
Keyfacts
Intellisys
Quality Underwriting
ExamOne
No Preference
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