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Beneficiaries Form Beneficiaries Form

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Country of origin: CANADA
File type: PDF

BROWSE OTHERS (CANADA) FORMS

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I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
Percent Relationship
Beneficiary: allocated: to plan member:
last name first name middle initial
last name first name middle initial
last name first name middle initial
To be divided as follows: As per the percentage indicated above, or
In equal shares to the survivor(s)
You may change this beneficiary designation at any time upon notice to Great-West Life. If you wish to make the
beneficiary designation irrevocable (meaning you may not change the designation or make certain changes to your
coverage under the plan without the written consent of the beneficiary) please complete form #M6348 BIL.
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
Great-West 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.
Plan number:
Plan sponsor:
Plan member name:
last name first name middle initial
Division number: Plan member ID:
BENEFICIARY DESIGNATION
For GWL Head Office Use Only
GWL Certificate Number
1. General Enrollment
Information.
3. Basic Life 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.
Please print clearly, in INK.
2. Basic Life Beneficiary
Designation
This section is to be completed
by the plan member.
This section must be completed
to designate a beneficiary for
your life benefits, if applicable.
The original of this form will be
required for a life claim.
Crossed out beneficiary
designations must be initialed.
Please print clearly, in INK
M6463(ONE-T-OL)-3/18
© The Great-West Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Great-West Life is strictly prohibited.
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 group benefits plan 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 Great-West 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.
Trustee last name first name middle initial Relationship to plan member
Page 1 of 3
Please print clearly and complete this form, in INK. The plan administrator should
keep a copy of thecompleted form for their records and send the original to:
For self-administered plans and GroupNet clients who maintain their own plan member’s records the plan administrator should attach this form to the plan
member’s application.
Cowan Insurance Group
700-1420 Blair Place
Ottawa, ON K1J 9L8
Trust plan administrator will complete
ONE-T
Not applicable
I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
Percent Relationship
Beneficiary: allocated: to plan member:
last name first name middle initial
last name first name middle initial
last name first name middle initial
To be divided as follows: As per the percentage indicated above, or
In equal shares to the survivor(s)
You may change this beneficiary designation at any time upon notice to Great-West Life. If you wish to make the
beneficiary designation irrevocable (meaning you may not change the designation or make certain changes to your
coverage under the plan without the written consent of the beneficiary) please complete form #M6348 BIL.
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
Great-West 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.
5. Optional Life 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.
Please print clearly, in INK.
4. Optional Life
Beneficiary
Designation
This section is to be completed
by the plan member.
This section must be completed
to designate a beneficiary for
your life benefits, if applicable.
The original of this form will be
required for a life claim.
Crossed out beneficiary
designations must be initialed.
Please print clearly, in INK
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 group benefits plan 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 Great-West 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.
Trustee last name first name middle initial Relationship to plan member
6. Privacy
This section explains
Great-West Life’s
commitment to privacy
Protecting Your Personal Information
At The Great-West Life Assurance Company, we recognize and respect the importance of privacy. When you
apply for coverage, we establish a confidential file that contains your personal information. This file is kept in the
offices of Great-West Life or the offices of an organization authorized by Great-West Life. You may exercise certain
rights of access and rectification with respect to the personal information in your file by sending a request in writing to
Great-West Life. Great-West Life may use service providers located within or outside Canada. We limit access to
personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to
perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal
information may be subject to disclosure to those authorized under applicable law within or outside Canada. Personal
information that we collect will be used for the purposes of determining your eligibility for coverage and administering the
group benefits plan. This includes investigating and assessing claims, and creating and maintaining records concerning
our relationship. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies
and practices (including with respect to service providers), write to Great-West Life’s Chief Compliance Officer or refer to
www.greatwestlife.com.
Page 2 of 3
7. Authorizations and
Declarations
This section must be signed
and dated in INK by the plan
member.
I have read and understand and agree with the contents of the section entitled “Protecting Your Personal Information”.
I authorize:
• Great-West Life, any healthcare provider, my plan administrator, any insurance or reinsurance company,
administrators of government benefits or other benefits programs, other organizations, or service providers
working with Great-West Life or the above to exchange personal information, when relevant and necessary to
determine my eligibility for coverage and to administer the plan.
I agree that a photocopy or electronic copy of this Authorizations and Declarations section is as valid as the original.
I certify that the information given is true, correct and complete to the best of my knowledge.
For Quebec applicants: I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
Plan member signature: Date:
Page 3 of 3
Clear
BENEFICIARY FORM BASIC
AND/OR OPTIONAL AD&D
General Information
If you make any corrections on this form, initial them to confirm that they are valid.
Please indicate the percentage of the benefit to be received by each beneficiary listed where multiple primary beneficiaries are named.
Beneficiaries (other than a spouse under a Quebec policy) are revocable unless you write the word "irrevocable" after that Beneficiary's name. If you
have an irrevocable beneficiary, your rights in the policy will be limited. The beneficiary must give written consent before you make changes, such as
future beneficiary changes or changes to your policy (e.g. decrease coverage). Note: Minor children cannot give written consent to these changes.
BENEFICIARY DESIGNATION
Policyholder Name:
Group Policy Number(s):
AB10519401/OE10519401
Employee Certificate Number:
I, _____________________________, hereby name the following revocable beneficiary(ies) for any benefits payable as a result of my coverage.
BASIC ACCIDENTAL DEATH AND DISMEMBERMENT BENEFICIARY DESIGNATION
Name of Beneficiary
Relationship
Percentage
For policies issued in Quebec only:
If you named your married or civil union spouse as a beneficiary, the designation is irrevocable unless you select revocable.
CONTINGENT BENEFICIARY (ALTERNATIVE)
I wish to appoint the following contingent beneficiary(ies) in the event my primary beneficiary predeceases me.
Name of Contingent Beneficiary
Relationship to Insured
OPTIONAL ACCIDENTAL DEATH AND DISMEMBERMENT BENEFICIARY DESIGNATION
Name of Beneficiary
Relationship
Percentage
For policies issued in Quebec only:
If you named your married or civil union spouse as a beneficiary, the designation is irrevocable unless you select revocable.
CONTINGENT BENEFICIARY (ALTERNATIVE)
I wish to appoint the following contingent beneficiary(ies) in the event my primary beneficiary predeceases me.
Name of Contingent Beneficiary
Relationship to Insured
Name of Insured Person
BENEFICIARY FORM BASIC
AND/OR OPTIONAL AD&D
APPOINTMENT OF TRUSTEE (ONLY COMPLETE IF APPLICABLE)
Complete this section if a beneficiary named on this form is a minor. If so, you agree that any benefit that becomes payable to a minor child will be paid
to the trustee to hold in trust for the child until the child comes of age.
Name of Trustee
Relationship to Minor Beneficiary
SIGNATURE
By signing below, you revoke any beneficiary designation or direction of payment that was previously made with respect to the proceeds payable under
the above policy and direct that proceeds be paid to the beneficiary(ies) listed on this form.
Signature of Insured Person
Date Signed
Signature of Irrevocable Beneficiary
Date Signed
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Beneficiaries Form Beneficiaries Form

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Completed 23 September 2021

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