The Manufacturers Life Insurance Company
GL4255E (06/2015) GP/MC
Page 1 of 2
Group Benets
Beneciary Designation
Please see reverse for assistance in completing this form.
Please send the completed form to your Plan Administrator.
All sections of this page should be completed as it will replace any prior designations.
1 Plan member information
Plan sponsor name Plan contract number Plan member certicate number
Plan member name (last, rst and middle initial) Province of residence Date of birth (dd/mmm/yyyy)
2 Primary beneciary
List all primary beneciaries for
Basic Life and/or Basic Accidental
Death.
Percentages must total 100% to
be valid.
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Irrevocability
Note: If beneciary is shown as irrevocable,
his/her consent is required to change it. Include
a signed and dated consent with this form. You
are responsible for ensuring the validity of
your designation.
For Quebec residents only
In Quebec, the designation of your spouse as beneciary is irrevocable
unless otherwise specied.
If spouse is beneciary, the designation is:
Revocable Irrevocable
3 Optional coverage
(if applicable)
Plan contract number
List all beneciaries for Optional
Life and/or Optional Accidental
Death.
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Irrevocability
Note: If beneciary is shown as irrevocable,
his/her consent is required to change it. Include
a signed and dated consent with this form. You
are responsible for ensuring the validity of
your designation.
For Quebec residents only
In Quebec, the designation of your spouse as beneciary is irrevocable
unless otherwise specied.
If spouse is beneciary, the designation is:
Revocable Irrevocable
4 Contingent beneciary
You may wish to designate a contingent beneciary(ies) to receive any proceeds under this group policy if all of
the primary beneciary(ies), named above for either coverage, should die before you. In that event, a contingent
beneciary will automatically be entitled to the benet that would have been payable to the primary beneciary(ies).
If you name more than one contingent beneciary, then the proceeds will be split, evenly, amongst the contingent
beneciaries you choose to name. Should there not be any surviving beneciaries at the time of your death, the
proceeds will be paid to your estate.
Name of contingent beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member
Name of contingent beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member
5 Trustee appointment
Complete if any beneciary named
is under the age of majority.
I appoint _______________________________________________________________ as Trustee to receive any amount due to
any beneciary under the age of majority (not applicable in Quebec).
6 Declaration and
authorization
Due to the legal signicance of
a beneciary appointment this
designation must be signed and
dated to be valid.
A copy, fax, scan or image of the
beneciary designation in this form
is as valid as the original.
I hereby revoke any previous beneciary designations in relation to my foregoing coverage(s) and designate the
person(s) named above.
At Manulife Financial, we know that condentiality of personal information is important. Any information you provide
to us will be kept in a Group Life and Health Benets le. Access to your information will be limited to:
• our employees and service representatives in the performance of their jobs;
• persons to whom you have granted access; and
• persons authorized by law.
You have the right to request access to the personal information in your le and, if necessary, correct any inaccurate
information.
I acknowledge that more detailed information concerning how and why Manulife Financial collects, uses and
discloses my personal information is available at www.manulife.ca/planmember, or by requesting a copy from my
plan sponsor.
Plan member signature Date signed (dd/mmm/yyyy)
Saint Mary's University
50231
A--------
NS
Print
The Manufacturers Life Insurance Company
GL4255E (06/2015) GP/MC
Page 2 of 2
Manulife Financial assumes no responsibility for the validity or sufciency of the content provided by you. The items ‘you’
and ‘yours’ refer to the plan member, the term “Plan Sponsor” refers to the entity that offers the group benets plan, such as
an employer.
What is the purpose of a beneciary?
If you intend for some or all of your death benet to go to specic individuals, it is important to make sure that you plan ahead
and select those beneciaries. Having an up-to-date beneciary designation will make this possible by listing your primary
and contingent beneciaries and intended allocations.
Beneciary: the person, people or entity who will receive any death benet from the basic or optional coverage you have
selected through your group benets plan that becomes payable upon your death. Basic and optional beneciaries may differ.
Types of beneciary – Primary vs. Contingent
Primary: the person, people or entity you choose to receive the death benets. If you choose more than one beneciary,
you will need to indicate what percentage of the benet you would like each person to receive. When multiple primary
beneciaries are named, the total of the percentages allocated to each primary beneciary must add up to 100%.
Contingent: the person, people or entity you designate to receive the death benets if all of the primary beneciaries die
before you. If you select more than one contingent beneciary, the benet will be split evenly between the contingent
beneciaries.
What happens to the death benet when...
The primary beneciary dies before you and no contingent
beneciary is named.
The death benet will be paid to your estate.
The primary beneciary dies before you, but there is a
contingent beneciary(ies) designated.
The benet will be paid to the contingent beneciary(ies).
You assign two primary beneciaries, and one beneciary
dies before you, and you have not updated your Beneciary
Form information.
The entire death benet that would have been paid to the
deceased beneciary will be paid to the surviving primary
beneciary.
Irrevocable vs. Revocable
Irrevocable: the beneciary you choose cannot be changed without the written permission of that individual.
For example, if you choose your spouse or partner to be the designated beneciary and you end up separating, you will not
be able to change the beneciary designation without a completed release form from them.
In Quebec, naming your spouse (must be a civil union) as a beneciary automatically means that he/she is an
irrevocable beneciary, unless you specify otherwise or divorce.
Revocable: A revocable beneciary means that the beneciary you choose can be changed at any time without the
permission of that individual.
For example, if you choose your spouse or partner to be the designated beneciary and you end up separating, you can then
change that beneciary designation without asking for that person’s permission.
Naming a minor as a beneciary
If a benet becomes payable to a minor who is named as a primary or contingent beneciary, the benet can only be paid
on behalf of the minor to a trustee or guardian for property, otherwise it will be paid into court to be held until the beneciary
has reached the age of majority for your specic province. It is important therefore, if you are choosing a beneciary who is a
minor at the time of the designation to also name a trustee.
If you are a Quebec resident, the parents are considered tutors of their child.
If a minor has been designated as an irrevocable beneciary, the policy is automatically frozen until the beneciary has
reached the age of majority for your specic province. A parent, guardian or trustee cannot consent to a beneciary change
on behalf of a minor.
Minor: a person named as a beneciary who is under the age of majority for your specic province.
Trustee: a person appointed by you to hold the minor’s proceeds in trust until the minor reaches the age of majority for your
specic province.
Tutor: a tutor acts like a trustee.
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