declaration of name

DECLARATION OF NAME
I, the undersigned, policyholder of contract number _____________________ request that the following changes be
made with respect to the name of the:
Policyholder
Beneficiary
Insured
The name of the person designated in the above-mentioned policy, shown as follows,
registered as:
_________________________________________
has been changed to: _________________________________________
REASON OF CHANGE:
Marriage ________ - _______ - _______
Year
Month
Day
Divorce ________ - _______ - _______
Year
Month
Day
Return to maiden name
Judgement authorizing a change of name (attach copy of judgement)
Erreur ______________________________________________________________________________________
Other
______________________________________________________________________________________
______________________________________________________________________________________
Signed at ___________________________________ this ______ day of __________________________ 20_____
Signature of witness:
_________________________________________
Signature of policyholder: _________________________________________
La Capitale assureur de l’administration publique inc.
La Capitale assurances et gestion du patrimoine inc.
625, rue Saint-Amable, case postale 16040, Québec (Québec) G1K 7X8
Declaration of name (2013-01-c)