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<br />BENEFICIARY DESIGNATION CHANGE FORM <br />PARTA–PERSONALINFORMATION <br />Employee Name EIN Province of Residence: <br />EmployeeElementarySecondary <br />ESPSSP(EA/ECE)PSSP PSSUUnion Exempt <br />Group: Teachers Teachers <br />Name of OCDSB Spouse (if applicable): EIN <br />PARTB–BENEFICIARYDESIGNATION(S) <br />PLEASE COMPLETE EACH SECTION FOR ALL BENEFICIARIES (QUOTES or DITTO’S ARE NOT VALID) <br />COVERAGE <br />NAME - LAST, FIRST, MIDDLE RELATIONSHIP TELEPHONE # DATE OF BIRTH PROCEED % <br />(must total <br />(under 18, <br />100%) <br />appoint Trustee) <br /> <br />BASIC ACCIDENTAL <br /> <br />DEATH AND <br />DISMEMBERMENT (AD/D) <br /> <br />RBC Policy # A808184 <br /> <br />GROUP LIFE – BASIC <br />(GRLIFE) <br />Manulife Policy # 91650 <br />GROUP LIFE – <br />VOLUNTARY <br />DIFFERENCE <br />(Former CBE Employees <br />Only) <br />OPTIONAL ACCIDENTAL <br />DEATH AND <br />DISMEMBERMENT (OAI) <br />RBC Policy # D808185 <br />OPTIONAL TERM LIFE <br />INSURANCE (OTL) <br />Manulife Policy # 91650A <br />RETIREMENT GRATUITY <br />Grandfathered for employees who <br />qualified to receive it and who <br />were employed with the OCDSB <br />prior to 1 Sept. 2012. <br />PARTC–CHILDRENUNDERTHEAGEOFMAJORITY <br />Please complete this section if you have designated a beneficiary who is under the age of majority. <br />I appoint _________________________________ as Trustee to receive any amount due to any beneficiary under the age of majority (18). If the <br />plan member is a Quebec resident, it is assumed a Trust agreement has been drawn up. <br />PARTD–QUEBECRESIDENTSONLY <br />In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified.I declare that my spouse is beneficiary, and the <br />designation is: <br /> Revocable Irrevocable* (see below note) <br />*Note: If your beneficiary designation was previously marked ‘irrevocable’, his/her consent is required to change your designation in the future. <br />Include a signed and dated consent with this form. Please note that you are responsible for ensuring the validity of your designation. <br />PARTE–AUTHORIZATIONANDSIGNATURE <br />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- <br />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 <br />spousal and/or dependent children coverage shall be me, if living, otherwise the proceeds will be payable to my Estate. I reserve the right to change this designation at <br />any time, in the manner that is in accordance with the provision of any law or regulation. I will inform my beneficiaries that I have named them as a beneficiary and <br />that they have 31 days in the event of my death to initiate a life claim with the OCDSB Human Resources. <br />Employee’s Signature: Date: <br />Please return this completed form to the OCDSB – HR Operations, 133 Greenbank Road, Nepean, ON, K2H 6L3 <br /> <br />