Public service management insurance plan - Members entitled to employer-paid coverage

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Initial application or change in coverage (select at least one of the following options)

For departmental use only part 1

To be completed by the applicant

Sex (select at least one of the following options)
Designation of this beneficiary is (select at least one of the following options)

Note - In Quebec, if you do not indicate whether the beneficiary designation is revocable, the designation of the legal is irrevocable

In all province/territories, as irrevocable beneficiary's written consent is required in order to make any change to the beneficiary designation.

I hereby apply for Supplementary Life Insurance (select at least one of the following options)
I wish (do not wish) to defer Supplementary Life Insurance coverage until the date my coverage under an employee Organization Group Plan ceases. My last day of coverage is

For departmental use only part 2

Public Service Management Insurance Plan

PWGSC-TPSGC 2028-7 (09/2015)