PWGSC-TPSGC 2017 - Election To Continue As A Participant Under The Supplementary Death Benefit (SDB) Plan

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Election To Continue as a Participant Under the Supplementary Death Benefit (SDB) Plan

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.

Plan Member's Personal Information

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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.

For Office Use Only

Instructions

  1. To constitute an election, this form must be completed and sent by mail to the following address within one year prior to, or within 30 days after ceasing to be employed:

    Public Works and Government Services Canada
    Public Service Pension Centre - Mail Facility
    150 Dion Blvd
    PO Box 8000
    Matane QC G4W 4T6

  2. This form IS NOT REQUIRED if the benefit entitlement is an immediate annuity for reason of age or disability or an immediate annual allowance. If approval of an immediate annuity due to disability is pending at termination, this form must be completed to guarantee continuation of coverage under the SDB plan.
  3. If proof of age has not been submitted to the Public Service Pension Centre (PSPC), it should accompany this form.
  4. You may name or change a beneficiary at any time by submitting a completed designation form PWGSC-TPSGC 2196. To obtain this form and further information, please refer to the Web portal Your Public Service Pension and Benefits or contact the Public Service Pension Centre.
  5. If your entitlement is a deferred annuity or an annual allowance payable later than 30 days after termination of employment, at the time the annuity becomes payable, the contributions will be deducted from your pension on a monthly basis, unless you advise the Public Service Pension Centre otherwise.

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)