The Manufacturers Life Insurance Company
GL4255E (06/2015) GP/MC
Page 1 of 2
Group Benets
Beneciary 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 certicate number
Plan member name (last, rst and middle initial) Province of residence Date of birth (dd/mmm/yyyy)
2 Primary beneciary
List all primary beneciaries for
Basic Life and/or Basic Accidental
Death.
Percentages must total 100% to
be valid.
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Irrevocability
Note: If beneciary 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 beneciary is irrevocable
unless otherwise specied.
If spouse is beneciary, the designation is:
Revocable Irrevocable
3 Optional coverage
(if applicable)
Plan contract number
List all beneciaries for Optional
Life and/or Optional Accidental
Death.
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Name of beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member Percentage
%
Irrevocability
Note: If beneciary 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 beneciary is irrevocable
unless otherwise specied.
If spouse is beneciary, the designation is:
Revocable Irrevocable
4 Contingent beneciary
You may wish to designate a contingent beneciary(ies) to receive any proceeds under this group policy if all of
the primary beneciary(ies), named above for either coverage, should die before you. In that event, a contingent
beneciary will automatically be entitled to the benet that would have been payable to the primary beneciary(ies).
If you name more than one contingent beneciary, then the proceeds will be split, evenly, amongst the contingent
beneciaries you choose to name. Should there not be any surviving beneciaries at the time of your death, the
proceeds will be paid to your estate.
Name of contingent beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member
Name of contingent beneciary (last, rst and middle initial) Date of birth (dd/mmm/yyyy) Relationship to plan member
5 Trustee appointment
Complete if any beneciary named
is under the age of majority.
I appoint _______________________________________________________________ as Trustee to receive any amount due to
any beneciary under the age of majority (not applicable in Quebec).
6 Declaration and
authorization
Due to the legal signicance of
a beneciary appointment this
designation must be signed and
dated to be valid.
A copy, fax, scan or image of the
beneciary designation in this form
is as valid as the original.
I hereby revoke any previous beneciary designations in relation to my foregoing coverage(s) and designate the
person(s) named above.
At Manulife Financial, we know that condentiality of personal information is important. Any information you provide
to us will be kept in a Group Life and Health Benets 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)
