5 - Voluntary accident insurance (Employee Paid)
Type of Plan:
Single Only Family Plan
I do not wish to purchase coverage
Benefit Amount Selected (Max Coverage $500,000 (Units of $10,000)
6A - Beneficiary information
New Change No Change
Beneficiary for Life Insurance (including Supplemental Life), Business Travel Accident and Voluntary Accident Insurance (if applicable).
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
MUST EQUAL 100%
If you are nominating a beneficiary who is a minor (under age 18), you must complete SECTION 6C. According to legal requirements, Sun Life Assurance
Company of Canada cannot pay benefits to beneficiaries who are minors, a TRUSTEE must be designated. If you do not nominate a beneficiary, the proceeds will
be paid to your estate and therefore may be subject to estate taxes and creditors. In Quebec, if you name your legal spouse (married or civil union) as the
beneficiary, this beneficiary will be irrevocable unless you check the revocable box. A revocable nomination can be changed at any time without the beneficiary's
consent. Your cannot change an irrevocable beneficiary nomination unless certain requirements are met.
Revocable Beneficiary
6B - Appointing contingent beneficiaries
New Change No Change
If there are no surviving beneficiaries at the time of my death, I declare that the following contingent beneficiaries shall receive the
proceeds. If there are no surviving contingent beneficiaries at the time of my death, the proceeds shall be paid to my estate. Unless I
specify otherwise, my contingent beneficiaries will apply to all my benefits.
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
MUST EQUAL 100%
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary
will be irrevocable unless you check the revocable box:
Revocable Beneficiary
6C - Nomination of trustee for minor beneficiary
If you wish to designate minor children (under the age of 18) as beneficiaries, a trustee must be designated. Any payments becoming
due while the beneficiary(ies) is a minor are to be made payable to
as trustee, or failing
such trustee to the duly appointed guardian of such minor child as trustee. Payment to the trustee will discharge Sun Life Assurance
Company of Canada. Details for Quebec residents will differ, please contact Human Resources.
Note: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on his/her behalf.
7 - Signature for beneficiary designation and privacy authorization
Please read this section carefully
You must be authorized to disclose information about your spouse and dependants in order to enrol them in the Plan.
By enrolling in this Plan, I authorize the following:
1. This signature for beneficiary designation below reflects my genuine wishes for nominating a beneficiary for Life Insurance (including
Supplemental Life), Business Travel Accident and Voluntary Accident Insurance (if applicable).
2. Sun Life Assurance Company of Canada, their agents and service providers to use and exchange information collected in this form to
underwrite, administer, adjudicate claims, and deposit claim payments.
3. My Plan Sponsor, Ryerson University, to use the information collected in this form for benefits administration, to disclose my salary
information and my Ryerson e-mail address to Sun Life Assurance Company of Canada and their agents and service providers for benefit
administration and to make any necessary payroll deductions which may be required for benefit administration.
I declare that the information above is accurate and true. Inaccurate information may invalidate my claim.
Please print this document and sign
A photocopy or electronic version of this signature is not valid for recording beneficiary nominations.
Employee Signature
Date
Location: 1 Dundas St. W. 16
th
floor Mail: 350 Victoria Street, Toronto, Ontario, Canada M5B 2K3
Tel: 416-979-5075 Fax: 416-979-5163 hr@ryerson.ca www.ryerson.ca/hr
