PWGSC-TPSGC 2451-1 - Post-retirement Life Insurance Plan (Change of Name/Change of Beneficiary)

Post-retirement Life Insurance Plan (Change of Name/Change of Beneficiary)

The information you provide is collected under the authority of Treasury Board for the administration of the Post-retirement Life Insurance Plan, verification of eligibility and statistical purposes. The completion of this form is required if you have recently changed your name or wish to change your beneficiary. All information will be protected under the provisions of the Privacy Act. Information will be placed in Personal Information Bank number PWGSC PCU 703 and the forms placed under registration PWGSC/ROS-080-03391. Access to this material is controlled by the Director General of Public Service Pension Centre.

Former Name

Present Name

I hereby revoke any previous beneficiary appointment which I may have made under the Post-retirement Life Insurance Plan and appoint the following beneficiary.

Now you have two choices. You must indicate YES to one option only.

Option 1

YES - I reserve the right to revoke this beneficiary designation

Option 2

YES - I wish to make an irrevocable beneficiary designation

I understand that written consent would be required from the named beneficiary(ies) if I wish to change this designation.

Where required by provincial law

If no beneficiary hereby designated survives me, the benefits payable upon my death are to be paid to my estate.

Insurance Section

We acknowledge receipt or your change of name/ beneficiary card

PWGSC-TPSGC 2451-1 (10/2011)