Fill - Free fillable Beneficiary Designation Form (Microsoft) PDF form

Beneficiary Designation Form

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EMPLOYEE SIGNATURE

Signature:

Date Signed:

(dd/mm/yyyy)

BENEFICIARY

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. If you are designating a trustee/

administrator, we recommend you consult with a legal advisor, and with any proposed trustee/administrator. If the minor resides in Quebec, you should consult with a Quebec Legal

counsel before completing this form.

I designate ______________________________________ relationship to Life Insured, ___________________________ as trustee/administrator to receive

any amount due to any beneficiary who is a minor until the age of majority and has legal capacity. At that time, the trustee shall deliver to the beneficiary all

assets held in trust.

Relationship to Insured

Please check Revocable

Irrevocable

Employee:

To be completed by the employee to designate a beneficiary for Group Life Insurance. Original copy of this form is required at time of claim.

EMPLOYEE INFORMATION (Please print clearly in ink and initial any errors/changes)

Last Name: First Name:

Date of Birth:

(dd/mm/yyyy)

REVOCABLE & IRREVOCABLE

Beneficiaries that are not stipulated revocable or irrevocable on this beneficiary designation form are assumed revocable, unless there are any court orders, separation agreements or other agreement that require

that all or any of the beneficiary designations be irrevocable. You may change a revocable beneficiary designation at any time. You may not change an irrevocable beneficiary designation or make certain changes

to your plan without the written consent of the irrevocable beneficiary.

Revocable: The designation of beneficiary can be changed without the beneficiary's consent.

Irrevocable: The designation of beneficiary cannot be changed without the beneficiary's consent.

Quebec Residents: The designation of a spouse as beneficiary is irrevocable unless otherwise specified.

All Other Provinces: The beneficiary designation is revocable unless otherwise specified.

BENEFICIARY TRUSTEE APPOINTMENT (only if Beneficiary is a minor)

Male

Female

Last Name:

First Name:

Gender: Date of Birth:

(dd/mm/yyyy)

Street Address:

PO Box: Unit #:

City:

Province: Postal Code:

Telephone: Email:

Relationship to Insured

Please check Revocable

Irrevocable

Last Name: First Name:

Date of Birth:

(dd/mm/yyyy)

Relationship to Insured

Please check Revocable

Irrevocable

Last Name: First Name:

Date of Birth:

(dd/mm/yyyy)

Relationship to Insured

Please check Revocable

Irrevocable

Last Name: First Name:

Date of Birth:

(dd/mm/yyyy)

This designation is for group life insurance benefit payable at the time of death. You can name anyone you wish as a your beneficiary.

If you name more than one beneficiary, or if the named beneficiary predeceases you and do not indicate a share percentage, the benefits will be divided equally to all surviving beneficiaries.

Please note the percentage allocated to your beneficiaries must total 100%. If no beneficiary is named, the life insurance is paid to your estate.

Please submit your completed application to:

Benecaid Health Benefit Solutions Inc. 185 The West Mall, Suite 800, Toronto, Ontario M9C 5L5

Email: changes@benecaid.com Fax: (416) 622-5312

Phone Local Number: 416-626-8786 Toll Free Phone: 1-877-797-7448 Toll Free Fax: 1-877-797-7449

Use of Your Information: The insurance you are applying for, or have been provided with, is underwritten by an insurer (the "Insurer") and is administered by Benecaid Health Benefit Solutions Inc. (“Benecaid”).

You agree that Benecaid and the Insurer may collect, use and disclose your information as described in the enclosed Privacy Agreement. You agree that you will only provide information about your spouse or

your dependent children, if each of them have authorized you to do so, and if each of them have consented to the collection, use and disclosure of his or her information as described in the enclosed Privacy

Agreement. Certification: You certify the information you have provided is true, correct and to the best of your knowledge. Communication: You consent to Benecaid communicating with you via email. Copies:

You agree that a photocopy or electronic copy of this section is as valid as the original.

AUTHORIZATION & DECLARATIONS:

Group Number:

Company Name:

v1.2 12142015

Beneficiary Trustee

Date of Birth:

(dd/mm/yyyy)

6. PRIVACY AGREEMENT

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In this Agreement, the words “you” and “your” mean any person who has requested from us, applied for, or is insured under any product or service offered, insured, reinsured,

administered or sold by us. The words “we”, “us” and “our” mean

(1) Benecaid Health Benefit Solutions Inc. and Benecaid Insurance Solutions Inc. (collectively "Benecaid") and any affiliates of Benecaid. (2) any insurance company that insures your

personal accident, sickness, life, travel, dental or other coverage provided through Benecaid; (3) any company that will in future provide coverage that replaces all or part of the

insurance coverage listed in (2) or any other insurance currently provided through Benecaid; (4) any company that provides reinsurance to any company listed in (1) through (3); and

(5) service providers for any company listed in (1) through (4).

The word “Information” means personal, health-related, financial and other details about you that you provide to us and we obtain from others outside our organization, including

through the products and services you use.

You acknowledge, authorize and agree as follows:

COLLECTING YOUR INFORMATION

At the time you begin a relationship with us and during the course of our relationship, we may collect Information directly by us, or through our representatives, including:

 details about you and your background, including your name, address, date of birth, occupation and other identification, all of which are required under law;

 information you provide through the application and claims process for any of our insurance products or services; and

 information for the provision of insurance products and services.

This Information may be collected from you and from sources outside our organization, including from:

 government agencies and registries, law enforcement authorities and public records;

 any healthcare professional, medically-related facility, insurance company, or other person who has knowledge of; your information

 other service providers, agents, brokers and other organizations with whom you make arrangements; other insurance companies;

 your employer; references you have provided; and

 persons authorized to act on your behalf under a power of attorney or other legal authority.

You authorize those sources to give us the Information.

USING YOUR PERSONAL INFORMATION

This information may be used for the following purposes:

 to administer your insurance and your trust accounts (if any); to communicate with you;

 to verify your identity and investigate your personal background; to investigate, adjudicate, manage and coordinate your claims;

 to arrange and maintain insurance products and other services you may request; to help us better manage our business and your relationship with us;

 to evaluate and underwrite insurance risk, re-price medical expenses and negotiate payment of claims expenses;

 to better understand your insurance situation; to offer you products and services to meet your needs; to determine your eligibility for insurance and non-insurance products and

services we offer;

 to detect and prevent fraud;

 to compile statistics; to help us better understand the current and future needs of our clients; and

 as required or permitted by law.

DISCLOSING YOUR INFORMATION

We may disclose your Information, including as follows:

 to other insurance companies, other financial institutions and health organizations;

 to any health-care professional, medically-related facility, insurance company or other person who has knowledge of your personal Information; to appropriate public health

authorities.

 to administrators, service providers, reinsurers and prospective insurers and reinsurers of our insurance operations, as well as their administrators and service providers for these

purposes;



 in response to a court order, search warrant or other demand or request, which we believe to be valid;

 to meet requests for information from regulators, including self-regulatory organizations of which we are a member or participant, to satisfy legal and regulatory requirements

applicable to us;

 to our employees, suppliers, agents and other organizations that perform services for you or for us or on our behalf;

 when we buy or sell all or part of our businesses or when considering such transactions;

 to help us collect a debt or enforce an obligation owed to us by you; and

 where permitted by law.

Telephone discussions – When speaking with one of our telephone service representatives, we may monitor and/or record your telephone discussions for our mutual protection, to

enhance customer service and to confirm our discussions with you.

MORE INFORMATION

Personal information or personal health information may be collected, used, disclosed, transferred, stored or processed outside of Canada and may therefore be subject to legal

requirements in such foreign countries. Full details regarding how your privacy is protected can be obtained by asking us for a copy of our Privacy Policy.

Please read our Privacy Policy for further details about this Agreement and our privacy policies. Visit www.benecaid.com or contact us for a copy.

You acknowledge that we may amend this Agreement and our Privacy Policy from time to time to reflect changes in legislation or other issues that may arise. We will post the revised

Agreement and Privacy Policy on our website listed above. You acknowledge, authorize and agree to be bound by such amendments.

If you wish to opt-out or withdraw your consent at any time for any of the opt-out choices described in this Agreement, you may do so by contacting us at: 1-877-797-7448. Please

read our Privacy Policy for further details about your opt-out choices.

Beneficiary Designation Form

Cont...

(Employee Name: ___________________________________________________________)

v1.2 12142015

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