Public Services and Procurement Canada
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Protected "B" when completed
I hereby revoke any previous beneficiary appointments which I may have made and appoint the following beneficiaries.
I reserve the right to revoke this beneficiary designation
Where required by provincial law:
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.
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.
We acknowledge receipt of your change of beneficiary card.
PWGSC-TPSGC 2028-1 (11/2002)