HomeMy WebLinkAboutOCDSB 736 Benef Desig Change Form
BENEFICIARY DESIGNATION CHANGE FORM
Salary & Benefits Administrator
Please return this completed form to OCDSB Human Resources
133 Greenbank Road, Nepean, ON K2H 6L3
PARTA–PERSONALINFORMATION
Employee Name EIN Province of Residence:
Name of OCDSB Spouse (if applicable): EIN
PARTB–BENEFICIARYDESIGNATION(S)
PLEASE COMPLETE EACH SECTION INDIVIDUALLY )
(Name, Relationship, Date of Birth and % of Proceeds
(Percentages must total 100% to be valid)
Please read before completing the formALSO
(QUEBEC residents please see PART D below): I hereby designate the following as
my beneficiary (ies) to receive any amount payable in accordance with the respective plans. I reserve the right to change this
designation at any time, in the manner that is in accordance with the provision of any law or regulation.
DATE OF BIRTH % OF
LAST NAME, FIRST NAME RELATIONSHIP
(YYMMDD PROCEEDS
Must total 100%
to be valid
BASIC ACCIDENTAL
DEATH AND
DISMEMBERMENT (AD/D)
RBC Policy # A808184
GROUP LIFE – BASIC
(GRLIFE)
Manulife Policy # 91650
GROUP LIFE –
VOLUNTARY DIFFERENCE
(Former CBE Employees Only)
OPTIONAL ACCIDENTAL
DEATH AND
DISMEMBERMENT
(OAI)
RBC Policy # D808185
OPTIONAL TERM LIFE
INSURANCE
(OTL0
Manulife Policy # 91650A
RETIREMENT GRATUITY
DEATH BENEFIT
Note:
In the event that you die while
an active employee of the OCDSB, any
entitlement to a retirement gratuity
may be paid to your estate or
designated beneficiary.
PARTC–CHILDRENUNDERTHEAGEOFMAJORITY
Please complete this section if you have designated a beneficiary who is under the age of majority.
not applicable
I appoint _________________________________ as Trustee to receive any amount due to any beneficiary under the age of majority (
in Quebec
)
PARTD–QUEBECRESIDENTSONLY
spouse
In Quebec, the designation of your as beneficiary is irrevocable unless otherwise specified.I declare that my spouse is beneficiary, and the
designation is:
Revocable Irrevocable* (see below note)
If your beneficiary designation was previously marked ‘irrevocable’, his/her consent is required to change it. Include a signed and dated
*Note:
. Please note that you are responsible for ensuring the validity of your designation.
consent with this form
PARTE–AUTHORIZATIONANDSIGANTURE
I hereby revoke any previous beneficiary designations in relation to my foregoing coverage(s) and designate the person(s) named above. I understand that if the above-
named beneficiary(s) predecease me and no other beneficiary has been appointed, the proceeds will be payable to my Estate. I understand that the beneficiary for
.
spousal and/or dependent children coverage shall be me, if living, otherwise the proceeds will be payable to my Estate
Employee’s Signature: Date:
OCDSB FORM 736
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