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GLFM-1233 Beneficiary Designation 1 of 3
Sun Life Assurance Company of Canada
Beneficiary Designation
You may use this form to designate who will receive the Group Life Insurance proceeds in the event of your death. The
designations you make on this form replace any prior beneficiary designations.
When applicable, designations apply to any Basic, Optional, Voluntary, Accidental Death and Dismemberment (“AD&D”),
or other Group Life Insurance you have under the Group Policy shown in Section 1.
See Page 3 of this form for sample beneficiary designations and more information.
1 | Employee and employer information
Name of employee
(first, middle initial, last)
Social Security number
Name of employer
Group policy number
Billing group number
2 | Beneficiary designation
For primary beneficiaries, indicate who should receive the group life or AD&D insurance proceeds in the event of your
death.
For secondary, (also known as contingent) beneficiaries, indicate who should receive the group life insurance proceeds in
the event that ALL of your primary beneficiaries are not living at the time of your death.
Please make your beneficiary designation(s) below. If you need more space, attach another sheet to this form.
You may designate more than one Primary or Secondary Beneficiary. If you do, make sure to indicate the percentage
share each should receive. The total within each class (Primary and Secondary) must equal 100%. If you do not specify
percentages, surviving beneficiaries within the class will share proceeds equally.
Primary Beneficiary(ies) Percent share
of proceeds*
1 Name (First, M.I., Last)
Social Security number
%
Address
Date of birth
2 Name (First, M.I., Last)
Social Security number
%
Address
Date of birth
DePauw University
202003
GLFM-1233 Beneficiary Designation 2 of 3
2 | Beneficiary designation, continued
Secondary Beneficiary(ies) Percent share
of proceeds*
1 Name (First, M.I., Last)
Social Security number
%
Address
Date of birth
2 Name (First, M.I., Last)
Social Security number
%
Address
Date of birth
* The total within each class (Primary and Secondary) must equal 100%.
3 | Signature
You must sign and date this form for your designation to become effective. Make a copy for your records and return the
signed original to your employer.
Name of employee
(first, middle initial, last)
Date
Contact us
www.sunlife.com/us
Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2016 Sun Life Assurance Company of Canada. Wellesley Hills, MA 02481. All rights reserved.
Sun Life Financial and the globe symbol are service marks of Sun Life Assurance Company of Canada.
GLFM-1233 Beneficiary Designation 3 of 3 3/16
4 | Beneficiary wording alternatives
Proposed Beneficiary(ies)
Suggested Wording
1. Estate
Estate
2. One beneficiary
Martha Doe, wife
3. More than one beneficiary in equal
shares
Jane Doe, Mary Doe and Richard Doe, children, or survivor(s) of them, in
equal shares.
4. Two beneficiaries, in succession
Primary: Martha Doe, wife; Secondary: Richard Doe, son. (Richard will
only receive proceeds if Martha Doe is not living at the time of the
employee’s death.)
5. One beneficiary followed by two
beneficiaries in equal shares
Primary: Martha Doe, wife; Secondary: Jane Doe and Mary Doe, children
in equal shares, or the survivor of them. (Jane and Mary will only receive
proceeds if Martha Doe is not living at the time of the employee’s death.)
6. More than one Beneficiary
in equal shares per descendent order
Jane Doe, Mary Doe and Richard Doe, or the survivor(s) of them, in equal
shares. However, if any of my children predecease me and leave issue
who survive me, the issue of the deceased child will receive their parents’
share in equal shares.
7. One or more minor children
John Smith, as custodian for Jane Doe, a minor, under the Uniform
Transfers to Minors Act (UTMA) so that proceeds can be paid before the
child reaches the age of maturity.
8. To a church or
non-profit organization
Name and address of the beneficiary organization.
9. Beneficiaries shown in percentages
John Smith, brother - 40%, or in the event of his death, to my estate; Alan
Smith, brother 60%, or in the event of his death, to my estate.
10. Trust under Last Will
and Testament
Proceeds to be paid to the Trustee under my Last Will and Testament.
11. Existing Trust
Jane Doe, Trustee of the Doe Family Trust, dated 1/1/2001.
Please Note:
You cannot name your Employer as a beneficiary for Group Life Insurance proceeds under the
Group Policy
. Unless you specifically instruct otherwise, your beneficiary designation will be revocable.
Dependent Life Insur
ance benefits are payable to the Employee. If the Employee does not survive the Dependent,
Dependent Life Insurance benefits will be paid to the Employee’s estate.
Sun Life Assurance Company of Canada is not a tax or legal advisor and the above information
is provided
as general information only. Before making beneficiary designations, you may want to consult with your tax
or legal advisor.
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Completed 22 July 2020

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