Employee Benefit Plan

Employee Benefit Plan

Beneficiary Designation Form

Complete this form if the employee wishes to designate a beneficiary(s) or change a previously designated beneficiary(s).

Please send originalsigned and datedform to:

SSBA

ATTN: Employee Benefits Dept.

400 – 2222 Thirteenth Ave

Regina, SK S4P 3M7

*ALL SHADED SECTIONS OF THIS FORM CAN BE COMPLETED ELECTRONICALLY – TAB FROM FIELD TO FIELD*

SCHOOL DIVISION / DIV#
1. EMPLOYEE INFORMATION
EMPLOYEE NAME (last, first, middle initial) / CERTIFICATE# / DATE OF BIRTH (PLEASE COMPLETE DATE AS EG: JANUARY 1, 2014)
2. LIST ALL BENEFICIARIES FOR BASIC LIFE AND BASIC ACCIDENTAL DEATH
PERCENTAGES MUST TOTAL 100% TO BE VALID
NAME OF BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
NAME OF BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
NAME OF BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
3. LIST ALL BENEFICIARIES FOR OPTIONAL LIFE AND/OR OPTIONAL ACCIDENTAL DEATH
PERCENTAGES MUST TOTAL 100% TO BE VALID
NAME OF BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
NAME OF BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
4. APPOINTING CONTINGENT BENEFICIARIES
IF THERE ARE NO SURVIVING BENEFICIARIES AT THE TIME OF MY DEATH, I DECLARE THAT THE FOLLOWING CONTINGENT BENEFICIARIES SHALL RECEIVE THE PROCEEDS. IF THERE ARE NO SURVIVING CONTINGENT BENEFICIRIES AT THE TIME OF MY DEATH, THE PROCEEDS SHALL BE PAID TO MY ESTATE. UNLESS I SPECIFY OTHERWISE, MY CONTINGENT BENEFICIARY(IES) WILL APPLY TO ALL MY BENEFITS.
NAME OF CONTINGENT BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
NAME OFCONTINGENT BENEFICIARY (last, first, middle initial) / RELATIONSHIP TO PLAN MEMBER / PERCENTAGE
%
TRUSTEE APPOINTMENT
COMPLETE IF ANY BENEFICIARY NAMED IS UNDER THE AGE OF MAJORITY
5.IAPPOINT / AS TRUSTEE TO RECEIVE ANY AMOUNT DUE TO ANY BENEFICIARY UNDER THE AGE OF MAJORITY.
6. SIGNATURE AND AUTHORIZATION
THIS DESIGNATION MUST BE SIGNED AND DATED TO BE VALID
THIS WILL REVOKE ALL PREVIOUS BENEFICIARY APPOINTMENTS
SIGNATURE / DATE SIGNED(PLEASE COMPLETE DATE AS EG: JANUARY 1, 2014)

FILLABLE BENEFICIARY DESIGNATION FORM –January 2014