Fillable F5A BENEFICIARY, TRUSTEE ASSIGNMENT FOR COLLATERAL, NAME CORRECTION (iA Financial Group)

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F5A BENEFICIARY, TRUSTEE ASSIGNMENT FOR COLLATERAL, NAME CORRECTION (iA Financial Group)

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F5A(18-09) PDF
Notes: • Corrected or altered forms will not be accepted.
• The policyowner(s) and the current and newly designated irrevocable beneficiary(ies) must sign each completed section of this form.
• For a designation of beneficiary on a universal life policy, sections 1 & 2 should be completed, if applicable.
• The expressions “assignees,” “legal heirs” and “estate” mean the policyowner’s heirs.
• The contingent beneficiary only acquires legal rights upon the death of the beneficiary to whom he/she is contingent.
• In Quebec, merely designating a trust as a beneficiary using this form does not create a trust. Individuals wishing to designate a trust
as a beneficiary are invited to consult a legal advisor.
Policy no.
Code CodeAgency Advisor S.U.
Last and first name of policyowner
1 • Designation of Beneficiary and Contingent Beneficiary
I hereby revoke any previous beneficiary designation for the insured(s) specified hereinafter and designate the following beneficiary(ies):
➡
For the insured: _________________________________________________________________________
the beneficiaries will be: and their contingent beneficiaries will be:
Beneficiary’s last and first name Sex Date of birth % Relationship Contingent beneficiary’s last and first name
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
Y - M - D
Y - M - D
2 • Designation of Beneficiaries for Funds
➡
The beneficiary of the accumulation fund and shuttle fund is/are:
The beneficiaries of insured 1
The policyowner
Other(s)
Beneficiary’s last and first name Sex Date of birth % Relationship
M Revocable
____________________________________________________________
F _________________________ ________ Irrevocable _______________________________
M Revocable
____________________________________________________________
F _________________________ ________ Irrevocable _______________________________
Signed at ____________________________________________ this ___________________________ day of _______________________20 ____
X______________________________________________ X______________________________________________ X______________________________________________
Advisor or witness Irrevocable beneficiary Policyowner
X______________________________________________
Policyowner
➡
For the insured: _________________________________________________________________________
the beneficiaries will be: and their contingent beneficiaries will be:
Beneficiary’s last and first name Sex Date of birth % Relationship Contingent beneficiary’s last and first name
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
➡
For the insured: _________________________________________________________________________
the beneficiaries will be: and their contingent beneficiaries will be:
Beneficiary’s last and first name Sex Date of birth % Relationship Contingent beneficiary’s last and first name
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
M Revocable
____________________________________
F ____________________ _____ Irrevocable __________________ ________________________________ Revocable
Signed at ____________________________________________ this ___________________________ day of _______________________20 ___
X______________________________________________ X______________________________________________ X________________________________________________
Advisor or witness Irrevocable beneficiary Policyowner
X________________________________________________
Policyowner
Y - M - D
Y - M - D
Choose ONE of
the three options.
}
BENEFICIARY, TRUSTEE
ASSIGNMENT FOR COLLATERAL, NAME CORRECTION
INDIVIDUAL LIFE INSURANCE
F5A
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
Validate and print
WARNING
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Please close this form, save on your Windows desktop, and open from an Adobe product.
3 • Designation of Beneficiaries for Critical Illness
➡
For the Critical Illness benefit for the insured whose name is ________________________________________________________ , the beneficiaries are:
Beneficiary’s last and first name Sex Date of birth % Relationship
M Revocable
_________________________________________________________________
F __________________________ ________ Irrevocable _______________________________
M Revocable
_________________________________________________________________
F __________________________ ________ Irrevocable _______________________________
➡
For the Return of premiums upon death for the insured whose name is ______________________________________________ , the beneficiaries are:
Beneficiary’s last and first name Sex Date of birth % Relationship
M Revocable
_________________________________________________________________
F __________________________ ________ Irrevocable _______________________________
M Revocable
_________________________________________________________________
F __________________________ ________ Irrevocable _______________________________
For the flexible return of premiums during the insured’s lifetime, the beneficiary is: Policyowner of the contract (applicant) or The insured
Signed at __________________________________________ this ___________________________ day of _______________________20 _____
X______________________________________________ X______________________________________________ X______________________________________________
Advisor or witness Irrevocable beneficiary Policyowner
X______________________________________________
Policyowner
4 • Designation of a Trustee for a Beneficiary – NOT APPLICABLE IN QUEBEC
Notes: • In Quebec, this section must not be completed since it will have no legal value. Please consult your legal advisor in this regard.
• For all other provinces, it is recommended that a trustee be appointed for any minor beneficiary or for any beneficiary who may not be able
to provide proper release.
I hereby appoint the following person as trustee to receive the benefits payable to any beneficiary who has not reached the age of majority or
who does not have the legal capacity to provide release.
This designation is revocable and applies until the said beneficiary reaches the age of majority.
Last name First name
___________________________________________________________________________________________________ ____________________________________________________
Name of trustee Relationship to insured
For the following beneficiary: ___________________________________________________________________________________________
Signed at __________________________________________ this ___________________________ day of _______________________20 ___
X______________________________________________ X______________________________________________ X_____________________________________________
Advisor or witness Policyowner Policyowner
5 • Assignment for Collateral Security
I hereby transfer and assign this contract to the assignee designated hereinafter as collateral security for a debt.
__________________________________________________________________________________________________________________________________________________________
Name of assignee
No. Street Apartment PO Box
__________________________________________________________________________________________________________________________________________________________
City Province Postal code
__________________________________________________________________________________________________________________________________________________________
Address of assignee
Signed at __________________________________________ this ___________________________ day of _______________________20 ___
X______________________________________________ X______________________________________________ X_____________________________________________
Advisor or witness Irrevocable beneficiary Policyowner
X_____________________________________________
Policyowner
6 • Name Correction/Change
I would like to correct the name of the policyowner the insured: ____________________________________________________________
Last name First name
to____________________________________________________________________________________________________________________________________________________
due to:
An error on the application Legal adoption Revert to maiden name Legal change
➡
Attach birth certificate
➡
Attach adoption papers
➡
Attach proof
➡
Attach proof
Signed at ____________________________________________ this ___________________________ day of ____________________20 ____
X_____________________________________________________________________ X________________________________________________________________________
Advisor or witness Policyowner
X________________________________________________________________________
Policyowner
➡
The policyowner and current beneficiary(ies) retain their rights on all benefits above
and beyond the debt.
➡
If change in beneficiary’s name, please complete Section 1.
Y - M - D
Y - M - D
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F5A BENEFICIARY, TRUSTEE ASSIGNMENT FOR COLLATERAL, NAME CORRECTION (iA Financial Group)

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Completed 2 March 2022

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