For plan members

Instructions

Important

  • Keep copies of all correspondence for at least 12 months.
  • Originals will not be returned.

Forms


Request for conversion – 14141E (PDF, 1 MB) Opens in a new window.

This form is used to exercise your life insurance conversion privilege.

Important:

This form must be filled within 31 days following the termination or reduction of your life insurance.


Declaration of Dependent Children Aged 18 to 25 or 21 to 25 Inclusive (According to Contract Provisions) – 19131A (PDF, 1 MB) Opens in a new window.

This form is used to report on or maintain the status of a dependent child who has reached the age of 18 or 21 (depending on the age limit stipulated in the policy).

Important:

This form is normally filled out and returned to us once a year at the beginning of each fall session. To learn more about the definition of dependent child, refer to your policy or contact your plan administrator.


Request for Designation or Change of Beneficiary(ies) or Trustee – 20007A (PDF, 564 KB) Opens in a new window.

This form is used to designate or change beneficiaries.

Important:

This form is needed to change an irrevocable beneficiary. The irrevocable beneficiary has to sign this form to give their consent. To find out more, read The Designation of Beneficiaries – 08137E (PDF, 214 KB) Opens in a new window.


Confirmation of a Dependent Child’s Functional Impairment – 09296E (PDF, 573 KB) Opens in a new window.

This form is used to advise us if a dependent child has a functional impairment.

Important:

One section of this form is completed by the attending physician.


Questionnaire on Smoking Habits – 02754A (PDF, 258 KB) Opens in a new window.

This form is filled out by the plan member to take advantage of the special non-smoker rate for certain benefits, if permitted by the contract.