3 How to submit this form
I,
as irrevocable beneficiary by
on
and
I am hereby waiving all the rights and privileges granted to me as irrevocable beneficiary under the said group
insurance policy. I am aware that as a result of this waiver, a new beneficiary may thus be designated by
that my rights and privileges will cease including the right to payment of the proceeds under the aforementioned
policy as of the signing date of this notice of waiver.
under the aforementioned group insurance policy.
, acknowledge having been designated
(Name of Irrevocable Beneficiary)
Plan member name
(date on which the Insured made the Beneficiary Designation)
(Plan member name)
Signature of beneficiary waiving rights
Witness (other than the plan member) for beneficiary waiving rights
Date (dd/mmm/yyyy)
Date (dd/mmm/yyyy)
When you name your beneficiaries online, we’ll prompt you to upload this form.
1 Plan member information
2 Waiver and signatures
Group Benefits
Notice of Waiver of Irrevocable Beneficiary Rights and Privileges
Fill out this form if you’re removing or changing an irrevocable beneficiary.
Plan sponsor name Plan contract number
Province of residence
Plan member certificate number
Date of birth (dd/mmm/yyyy)Plan member name (last, first and middle initial)
Please print clearly.
Please sign and date as
indicated.
The Manufacturers Life Insurance Company
GL5201E(DIGITAL) (01/2021)
