PWGSC-TPSGC 2451-1: Post-retirement life insurance plan (Change of name/change of beneficiary)

Privacy notice

The information you provide is collected under the authority of Treasury Board for the administration of the Post-retirement Life Insurance Plan, verification of eligibility and statistical purposes. The completion of this form is required if you have recently changed your name or wish to change your beneficiary. All information will be protected under the provisions of the Privacy Act. Information will be placed in Personal Information Bank number PWGSC PCU 703 and the forms placed under registration PWGSC/ROS-080-03391. Access to this material is controlled by the Director General of Public Service Pension Centre.

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Instructions for fillable PDF forms

PWGSC-TPSGC 2451-1 - Post-retirement life insurance plan (Change of name/change of beneficiary) [PDF - 59 KB]

Protected "B" when completed

Pension Number

Change

Change of Name Change of Beneficiary

Former name

Former Name Full Family Name of Participant

Former Name Given Name

Present name

Present Name Full Family Name of Participant

Present Name Given Name

I hereby revoke any previous beneficiary appointment which I may have made under the Post-retirement Life Insurance Plan and appoint the following beneficiary.

Full Family Name of Beneficiary

Given Name

Relationship of Beneficiary to participant

Address of Beneficiary

Now you have two choices. You must indicate YES to one option only.

Option 1

YES - I reserve the right to revoke this beneficiary designation

Option 1 Signature

Option 2

YES - I wish to make an irrevocable beneficiary designation

I understand that written consent would be required from the named beneficiary(ies) if I wish to change this designation.

Option 2 Signature

Where required by provincial law

I, (Signature of previous beneficiary), consent to the appointment of another beneficiary.

If no beneficiary hereby designated survives me, the benefits payable upon my death are to be paid to my estate.

Address of participant

Participant Signature

Participant signature Date (Y-M-D)

Witness Signature

Witness signature Date (Y-M-D)

Insurance section

Participant's Name

Address

We acknowledge receipt or your change of name/ beneficiary card

Insurance Clerk

Insurance clerk signature Date (Y-M-D)

PWGSC-TPSGC 2451-1 (10/2011)

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From:

Public Services and Procurement Canada

Page details

2025-08-15

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