Signature of Witness
I, the policy owner confirm that the named beneficiary(ies) will cancel and replace all previous beneficiary and trustee designations.
(If policy has multiple owners, all owners must sign. If company is owner, please specify officer’s name and title). Any appointment of
a beneficiary or any change is effective when received by Equitable Life of Canada. We assume no responsibility or liability for the
validity or effect of any appointment or change. Any payments made will be in accordance with applicable laws.
Signature(s) of Policy Owner Date
(city and province)
Signed in on
(dd/mm/yyyy) Signature of Irrevocable Beneficiary(ies) Signature of Witness
Print name of Irrevocable Beneficiary(ies) Print name of Witness
(city and province)
Signed in on
(dd/mm/yyyy) Signature of Irrevocable Beneficiary(ies) Signature of Witness
Print name of Irrevocable Beneficiary(ies) Print name of Witness
If Applicable, Release of Interest as Irrevocable Beneficiary:
BENEFICIARY CHANGE REQUEST FORM
THE EQUITA B L E L I F E I N S U R A N C E C O M PA N Y O F C A N A D A
671BCF(2016/12/30) Page 2 of 3
Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor
(dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
Name (First, Middle, Last)
Relationship
to Insured
Benefit shared equally
unless % specified
Date of Birth if a
minor (dd/mm/yyyy)
Name of Trustee for
minor
(not applicable in PQ)
Critical Illness Beneficiary: For benefits payable while life insured is alive. I designate the following beneficiary(ies):
Critical Illness Beneficiary: Return of premium on death. I designate the following beneficiary(ies):
Ensure both pages of this form are submitted for processing
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.800.668.4095.