Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor (dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
BENEFICIARY CHANGE REQUEST FORM
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 T 519.886.5210 F 519.883.7404
www.equitable.ca
Policy # Policy # Policy #
Name (First, Middle, Last) Date of Birth (dd/mm/yyyy) Phone #
Policy
Owner(s):
Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor (dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
List the policy number(s) for which you would like to change the beneficiary:
Primary Beneficiary Change: The primary beneficiary(ies) receives the policy benefits when the insured person dies.
I designate the following Primary beneficiary(ies):
Contingent Beneficiary Change: The contingent beneficiary(ies) receives the policy benefits if all the primary beneficiaries are
deceased at the time of the insured’s death. I designate the following Contingent beneficiary(ies):
Beneficiary will be revocable unless stated to be irrevocable. Where Quebec law applies, if you name your spouse (married or
civil union) as beneficiary, it is irrevocable unless you stipulate it as revocable by checking here
£ Revocable
Ensure both pages of this form are submitted for processing
THE EQUITA B L E L I F E I N S U R A N C E C O M PA N Y O F C A N A D A
671BCF(2016/12/30) Page 1 of 3
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.800.668.4095.
Signature of Witness
I, the policy owner confirm that the named beneficiary(ies) will cancel and replace all previous beneficiary and trustee designations.
(If policy has multiple owners, all owners must sign. If company is owner, please specify officer’s name and title). Any appointment of
a beneficiary or any change is effective when received by Equitable Life of Canada. We assume no responsibility or liability for the
validity or effect of any appointment or change. Any payments made will be in accordance with applicable laws.
Signature(s) of Policy Owner Date
(city and province)
Signed in on
(dd/mm/yyyy) Signature of Irrevocable Beneficiary(ies) Signature of Witness
Print name of Irrevocable Beneficiary(ies) Print name of Witness
(city and province)
Signed in on
(dd/mm/yyyy) Signature of Irrevocable Beneficiary(ies) Signature of Witness
Print name of Irrevocable Beneficiary(ies) Print name of Witness
If Applicable, Release of Interest as Irrevocable Beneficiary:
BENEFICIARY CHANGE REQUEST FORM
THE EQUITA B L E L I F E I N S U R A N C E C O M PA N Y O F C A N A D A
671BCF(2016/12/30) Page 2 of 3
Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor
(dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor (dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
Critical Illness Beneficiary: For benefits payable while life insured is alive. I designate the following beneficiary(ies):
Critical Illness Beneficiary: Return of premium on death. I designate the following beneficiary(ies):
Ensure both pages of this form are submitted for processing
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.800.668.4095.
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.800.668.4095.
BENEFICIARY CHANGE REQUEST FORM
THE EQUITA B L E L I F E I N S U R A N C E C O M PA N Y O F C A N A D A
671BCF(2016/12/30) Page 3 of 3
Instructions for Beneficiary Designations:
1. If no beneficiary is named, the proceeds will be paid according to applicable law.
2. If a beneficiary is to be designated as irrevocable, that must be specified next to the beneficiary’s name. If the beneficiary
designation is specified as irrevocable, the signature of the irrevocable beneficiary is required to make any future beneficiary
changes. If the current beneficiary is designated irrevocable, the beneficiary change will not be effective unless the
irrevocable beneficiary releases their interest as a beneficiary.
3. Where Quebec law applies designation of the owners spouse (married or civil Union) is irrevocable, unless the owner
stipulated the designation to be revocable.
4. If a trust is designated for a minor beneficiary, the proceeds will be paid to the trustee as long as the beneficiary is a minor.
Once the minor beneficiary reaches the age of majority, the proceeds will be paid directly to him or her, according to
applicable law. This does not apply in Quebec.
5. If a trust is designated as a beneficiary, ensure the full and complete name of the trust is listed.
6. List name of children individually instead of “All my children” to avoid delay in receiving proceeds at time of claim.
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