Grandeur Beneficiary Form

Grandeur Beneficiary Form

BENEFICIARY INFORMATION – ALL INFORMATION IS REQUIRED

I hereby assign the following individual(s) as my beneficiary. Your beneficiary will automatically default to your “ESTATE” if you fail to complete this section. Unless Otherwise Stipulated Or Prohibited By Law, The Designation Is Revocable. If The Beneficiary Is Shown As Irrevocable, His/Her consent is required to change it.
Appointment beneficiary's Last name
Appointment beneficiary's first name
Appointment beneficiary's date of birth
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change.
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change
Note: If beneficiary is shown as irrevocable, his/her consent is required to change it. Include a signed and dated consent with this form. You are responsible for ensuring the validity of your designation.
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
TRUSTEE DESIGNATION: This section is to be completed only if the beneficiary designated above is under the age of majority

DECLARATION & AUTHORIZATION – MUST SIGN AND DATE

I disclose the person name(s) under Beneficiary Designation as the appointed Beneficiary (s). I confirm that the information provided on this form is true and complete, and understand that if any of the information is incomplete or false my benefits can be terminated. I acknowledge that I am authorized to disclose and receive information about my spouse and/or dependents. the Plan Administrator, its agents, insurers and service providers are authorized to use and exchange information on this form to underwrite, administer, determine eligibility and adjudicate claims. I understand that Personal Information collected with this Application for Insurance is confidential and will not be used or any purpose other than in conjunction with this request form, and subsequent administration of, the Group Insurance protection that is afforded to Applicants, Spouses, and Dependent Children under this plan. I authorize the Plan Administrator to recover any payments made in error.
MM slash DD slash YYYY

PRIVACY & CONFIDENTIALITY

We protect our Customers’ confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents’ benefits. In terms of telephone inquiries to the Plan Administrator, Customer Service, the information provided varies based on the relationship of the person making the inquiry to the insured (e.g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only the information pertaining to the specific claim or treatment in question is shared.

EMPLOYER AUTHORIZATION – MUST SIGN AND DATE

I declare that the information provided above is accurate and true, and hereby authorize the Plan Administrator to use this information to administer the Group Benefits; obtain quotes for underwritten/insured products within the plan; verify the identity and eligibility of the plan member, spouse or eligible dependents; adjudicate and pay eligible claims; audit plans and prepare reports. I understand that this information will only be provided to those insurers affiliated with the Plan Administrator and acknowledge that I have obtained the consent of this Employee and Spouse/Partner to provide this information.
MM slash DD slash YYYY