Public Services and Procurement Canada
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Protected "B" when completed
Provision of the information requested on this form is required in accordance with the Public Service Superannuation Act (PSSA). The personal information collected is for continuing coverage under the Supplementary Death Benefit (SDB) plan after termination of employment. Refusal to supply the personal information on this form may result in your SDB plan coverage not continuing after termination of employment. The personal information will be maintained in the Personal Information Bank Number PWGSC PCE 702 and will be protected, used and disclosed in accordance with the Privacy Act. Under this act, you have the right to request access and correct your personal information, if erroneous or incomplete. The information will be retained by the department for two years following the last administrative action, and then destroyed.
This form must be completed electronically. If not possible, please complete it in dark ink using capital letters.
Election: I hereby elect to continue to be a participant under the Supplementary Death Benefit Plan in accordance with the terms of Part II of the Public Service Superannuation Act. I understand that coverage is based on twice my total salary, which includes applicable pensionable allowances, rounded to the next multiple of $1000 as of my termination date or the date my public service pension plan membership status changed. I also understand that contributions are based on my age and the amount of my coverage and will be charged at commercial rates. I am making this election no later than 30 days after ceasing to be employed or the date my public service pension plan status changed.
Public Works and Government Services Canada
Public Service Pension Centre - Mail Facility
150 Dion Blvd
PO Box 8000
Matane QC G4W 4T6
Caution: You should submit the annual contribution with this form within 30 days after ceasing to be employed or the date your public service pension plan membership status changed. In no case will contributions be accepted if received more than 60 days after ceasing to be employed or after a change in your public service pension plan membership status. To obtain the annual contribution amount, refer to the Supplementary Death Benefit (SDB) Estimates Statement provided to you or call the Public Service Pension Centre to obtain the annual contribution amount.
PWGSC-TPSGC 2017 (12/2009)