PWGSC-TPSGC 2028-1 - Public Service Management Insurance Plan

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Protected "B" when completed

Public Service Management Insurance Plan

Management Insurance Plan Change

Change of Name Change of Beneficiaries

Individual Agency Number (IAN)

Former Name

Member's Surname

Given Names

Present Name

second option Member's Surname

second option Given Names

I hereby revoke any previous beneficiary appointments which I may have made and appoint the following beneficiaries.

Beneficiary Beneficiary's Surname

Beneficiary Given Names

Beneficiary Relationship of Beneficiary to You

Beneficiary Address of Beneficiary

Beneficiary Line 1

I reserve the right to revoke this beneficiary designation

Yes No

Second Beneficiary Beneficiary's Surname

Second Beneficiary Given Names

Second Beneficiary Relationship of Beneficiary to You

Second Beneficiary Address of Beneficiary

Beneficiary Line 2

I reserve the right to revoke this beneficiary designation

Second Beneficiary Yes Second Beneficiary No

Third Beneficiary Beneficiary's Surname

Third Beneficiary Given Names

Third Beneficiary Relationship of Beneficiary to You

Third Beneficiary Address of Beneficiary

Beneficiary Line 3

I reserve the right to revoke this beneficiary designation

Third Beneficiary Yes Third Beneficiary No

Where required by provincial law:

Signature of Previous Beneficiary

consent to the appointment of another beneficiary.

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

Department or Agency

Location

Telephone Number

Member's Address

Member's Signature

Date (Y-M-D)

Witness' Signature

Date (Y-M-D) 2

Provision of the information requested on this document is voluntary. This information is collected for the administration of the Public Service Management Insurance Plan and is essential to making a decision directly affecting you. The completion of this form is required if you have changed your name or wish to change your beneficiaries. Refusal to respond may result in not making the changes requested. This information will be stored in Personal Information Bank Number PWGSC PCE 703. It is protected from disclosure to unauthorized persons or agencies pursuant to the provisions of the Privacy Act. Under the Act you have the right to request access to your personal information, held by a federal government institution, and to request corrections should you believe the information contains errors or omissions. Personal information that you provide about another individual may be accessible to that person under the Privacy Act.

Insurance Section

Insurance section Member's Name

Insurance section Address

We acknowledge receipt of your change of beneficiary card.

Insurance section Insurance Clerk

Insurance section Date (Y-M-D)

PWGSC-TPSGC 2028-1 (11/2002)