last name first name middle initial
last name first name middle initial
last name first name middle initial
Policy number: ID number:
Policyowner name:
last name first name middle initial
Please print clearly, in INK.
Please print clearly, in INK.
Please print clearly and complete this form, in INK.
Trustee last name first name middle initial Relationship to plan member
CONTINUE ON REVERSE SIDE Page 1 of 2
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M5981(IHP)-9/19
Canada Life and design are trademarks of The Canada Life Assurance Company.
ACCIDENTAL DEATH
BENEFICIARY DESIGNATION
Please keep a copy of the completed form for your records and send the original to
The Canada Life Assurance Company at the address provided on bottom of page 2.
1. General Enrollment
Information
2. Beneficiary
Designation
This section is to be completed
by the policyowner.
This section must be completed
to designate a beneficiary
for your death benefit under
the accidental death and
dismemberment and specific
loss benefit rider, if applicable.
The original of this form will be
required for a life claim.
Crossed out beneficiary
designations must be initialed.
I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
Beneficiary:
Percent
allocated:
Relationship
to plan member:
Note: If percentages are allocated, they must total 100% (if percentages are allocated to some beneficiaries but
not all, those beneficiaries who do not have allocations are considered to have been allocated equal percentages
to cover the unallocated balance). If no percentages are allocated, the beneficiaries are considered to be allo-
cated for equal percentages. The percentage allocation for any beneficiary who does not survive the insured is
divided equally among those beneficiaries who do survive the insured.
You may change this beneficiary designation at any time upon notice to Canada Life. If you wish to make a beneficiary
designation change please contact Canada Life at the phone number provided on the back of this form.
Note: Where Quebec law applies and you have designated your married spouse or civil union spouse as
beneficiary, the designation will be irrevocable unless you check the box marked “Revocable”, below.
I hereby make the above beneficiary designation:
Revocable, I may change this beneficiary designation at any time
For Quebec Applicants Only - Benefits payable under this plan to a beneficiary who, at the time payment is to be
made, is a minor or lacks legal capacity, will be paid to his/her tutor(s) or curator(s), unless a valid trust has been
established for the benefit of the beneficiary, by Will or by separate contract, to receive any such payment and
Canada Life has been provided notice of the trust. If a valid trust has already been established, designate the trust
as the beneficiary in this section. Before designating a trust, you should seek legal advice.
3. Trustee Appointment
You may wish to appoint a
trustee/administrator by
completing this section
The original of this form will be
required for a life claim.
DO NOT COMPLETE THIS SECTION IF YOU ARE A QUEBEC RESIDENT
If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a trustee/
administrator by completing this form. This appointment may not be suitable for all purposes.
If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any
proposed trustee/administrator.
Do not complete this section if you have made another trustee/administrator appointment.
I hereby appoint the following trustee to receive and to hold in trust, on behalf of any beneficiary, money payable to
the beneficiary under this policy where, at the time payment is to be made, the beneficiary is a minor or otherwise
lacks legal capacity. Any such payment, to its extent, will release The Canada Life Assurance Company from further
liability. The trustee shall act prudently and may use the money, including any returns on it or investments made,
for the education and/or maintenance of the beneficiary. The trust will terminate once the beneficiary is of the age
of majority and has legal capacity. At that time, the trustee shall deliver to the beneficiary all assets held in trust.
