Fillable Group Benefits Enrolment Form (Page 3 of 3) in pdf

Beneficiary nomination

Beneficiary for Employee BASIC Life and Accidental Death Benefits (if applicable)

You must initial any changes or deletions. Correction fluid cannot be used.

Last name

First name

Relationship to plan member

Percentage

Last name

First name

Relationship to plan member

Percentage

Last name

First name

Relationship to plan member

Percentage

In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check



the revocable box.

Revocable beneficiary

A revocable nomination can be changed at any time without the beneficiary’s consent. You cannot change an irrevocable beneficiary

nomination unless certain requirements are met.

If you do not nominate a beneficiary, the proceeds will be paid to your estate.

If you are nominating a beneficiary who is a minor, please see section 9.

Appointing contingent beneficiaries –

please complete this section if you wish to appoint a contingent beneficiary

If there are no surviving beneficiaries at the time of my death, I declare that the following Contingent Beneficiaries shall receive the pro-

ceeds. If there are no surviving Contingent Beneficiaries at the time of my death, the proceeds shall be paid to my estate.

Unless I specify otherwise, my Contingent Beneficiary will apply to all my benefits.

Last name

First name

Relationship to plan member

Percentage

Last name

First name

Relationship to plan member

Percentage

Last name

First name

Relationship to plan member

Percentage

In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check



the revocable box.

Revocable beneficiary

Nomination of trustee for minor beneficiary other than Quebec residents

If you wish to designate minor children as beneficiaries, a trustee must be designated.

Any payments becoming due while the beneficiary(s) are a minor* are to be made to

_______________________________________________________

as trustee, or failing such trustee to the duly appointed guardian of such

minor child as trustee. Payment to the trustee will discharge the company.

* A minor is a child who has not reached the age of majority as defined by provincial legislation.

NOTE: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on his/

her behalf.

Authorization and signature –

you must sign and date the form

I am authorized to disclose information about my spouse and dependents in order to enrol them in the plan.

By enrolling in this plan, I authorize the following:

• Sun Life Assurance Company of Canada and its reinsurers to collect, use and disclose relevant information about me to

underwrite, administer, adjudicate and deposit claim payments,

• My plan sponsor to use the information collected in this form for benefits administration and to make any necessary

payroll deductions which may be required,

• Sun Life Assurance Company of Canada and my plan sponsor to collect, use and disclose information about me, my

spouse and dependents necessary for enrolment and for the purposes of continuing administration of the plan.

I declare that the information above is accurate and true.

A photocopy or electronic version of this authorization is as valid as the original. A photocopy or electronic version of this

form is not valid for recording beneficiary nominations.

Plan member signature

Date (yyyy-mm-dd)

–

Page 3 of 3

942-2755-BI-08-13

Group Benefits Enrolment Form Page 3

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