SSQ Optional Life Insurance Application - Benefits by Design 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, 'Employer Information.' Fill in the Policy Holder Name, SSQ Group #, Division Name, and Certificate # using block letters.
3. Move to Section B, 'Participant Information.' Enter your Last Name, First Name, S.I.N., preferred Language (English or French), Mailing Address including postal code, Telephone number, Gender (M/F), and Date of Birth.
4. In Section C, 'Request for Optional Life Insurance Coverage,' indicate the coverage amounts for both yourself and your spouse. Specify if you are requesting additional coverage and provide details on current coverage.
5. Complete Section D regarding Smoking Habits by selecting Non-Smoker or Smoker for both yourself and your spouse.
6. In Section E, designate your beneficiary(ies) and specify their relationship to you. Choose between revocable or irrevocable status.
7. Sign and date the form in Section F under 'Participant Authorization' to confirm all information is accurate.
8. Finally, have your employer complete Section G for authorization before submitting the application.

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