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Summary: Queen's University - Pensions and Insurance
Life Insurance Beneficiary Change - Group Policy No. 139046
Name:
Dept. or Address:
Employee No.: Effective Date:
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Life Insurance
_ APPOINTMENT OF NEW BENEFICIARY - I hereby revoke any Designation of Beneficiary heretofore made by me and hereby appoint as
Designated Beneficiary to receive any payment upon my death under said group policy.
(Given names in full) (Last Name) (Relationship to Employee)
_________________________ _______________________ MY ________________________
_________________________ _______________________ MY ________________________
_________________________ _______________________ MY ________________________
TO BE DIVIDED AS FOLLOWS (IF APPLICABLE):
_ In equal shares or to the survivor(s) _ Other ( Please Specify)
_________________________________________________________________
TRUSTEE CLAUSE (If appointing a minor beneficiary you may wish to complete this section):
I hereby nominate and appoint __________________________________________________ my _______________________________________ ,
if living, (Full given names) (Relationship to Employee)
to receive and disburse any moneys payable under the said group policy to my beneficiary(ies) during minority, and any payments made to the
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