One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.800.265.4556 F 519.883.74 03
PLAN MEMBER GROUP LIFE AND AD&D INSURANCE BENEFICIARY DESIGNATION
Name of Policyholder:
Group Policy Number: Division Number:
Plan Member’s Name:
First, Middle, Last
Plan Member’s Certificate #:
Plan Member’s Date of Birth: Plan Member’s Class:
NOTE: If no beneficiary is appointed, the proceeds shall be paid as required by provincial law. If more than one beneficiary is appointed,
proceeds will be payable in equal shares, unless otherwise indicated. The insured Plan Member can change the appointed beneficiaries at any
time unless the designation is made irrevocable, in which case, the irrevocable beneficiaries’ written consent is required.
I revoke any previous designated beneficiaries and designate the following beneficiaries to receive the proceeds:
Name of Primary Beneﬁciary (First, Middle, Last) Relationship to Plan Member % Share
If the above Primary Beneficiaries pre-decease me, I designate the following contingent beneficiaries to receive the proceeds:
Name of Contingent Beneﬁciary (First, Middle, Last) Relationship to Plan Member % Share
NOTE: If both the Primary Beneficiaries and Contingent Beneficiaries predecease the insured Plan Member, the proceeds will be paid as
required by provincial law. If there are additional Primary and/or Contingent Beneficiaries, please sign, date and attach a note to this form
with the beneficiary information.
NOTE: For Quebec residents, designating your spouse as beneficiary is irrevocable unless you make the designation revocable. An irrevocable
beneficiary designation cannot be changed without the written consent of the irrevocable beneficiary. A revocable beneficiary designation can
be changed at any time without the consent of the revocable beneficiary.
I elect to make my spouse designation:
If the beneficiary(ies) is/are under the age of majority at the time of my death, proceeds of the policy shall be payable to the following except in Quebec:
Name of Trustee (First, Middle, Last)
Relationship to Plan Member
The personal information willingly provided by me to my Plan Sponsor, the independent broker/sales advisor and Equitable Life, collected on this form and held in their files, will be used by Equitable
Life for the purposes of servicing, administration, claims processing and adjudication related to this form, the Group Insurance Policy and all benefits thereunder, and any supplementary documents.
I understand and authorize that for the above purposes the personal information on file is accessible to, and may be exchanged with, authorized employees of, and relevant third parties retained by
Equitable Life, participating reinsurer(s), other insurance companies, investigative organizations, health care providers, including, but not limited to pharmacies, physicians and dentists and any other
person or party whom I authorize.
I CERTIFY THAT ALL OF THE INFORMATION GIVEN ON THIS FORM IS TRUE, CORRECT AND COMPLETE AND I DESIGNATE THE BENEFICIARIES STATED ABOVE.
Date: Plan Member’s Signature:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA