Death Benefits Form - www.seafarers.ca

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If you require a PDF version of the form below, please email medical@seafarers.ca to receive a copy.

Member Information

Name

First

Last

Name Member of

Union Number

Found in your SIU Membership Book

Reference Number

Found in your SIU Membership Book

Phone Number

Email

Date of birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Beneficiary Information

Revocation and Nomination of Beneficiary

I hereby revoke all previous nominations of beneficiary of death benefit payable under the seafarers' medical plan and make the following nomination of beneficiary with respect to the death benefits provided now or any time in the future under the regulations of the SMP still reserving to myself the privilege of future changes of beneficiary.

Name of Beneficiary

First

Last

Relationship to Seafarer

Beneficiary Phone Number

Beneficiary Email

Address of Beneficiary

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Signature of Seafarer

Clear Signature

Date of signature