Statement Date: [!STATEMENT DATE]
Employee number: [!EMPLOYEE NUMBER]
[!FIRST NAME] [!LAST NAME] [!ADDRESS] [!CITY], [!PROVINCE] [!POSTALCODE]
This notice confirms your recent beneficiary designation(s) request.
By agreeing to the terms and conditions when submitting your electronic beneficiary designation at the end of your enrollment is considered by Blue Cross as an electronic signature. You do not have to return a signed form.
All changes to your beneficiary designation will have to be made electronically by accessing the online enrollment system.
Please retain a copy for your records.
Insurance Company [!CARRIER NAME] Group Policy No. [!POLICY NUMBER]
[!BENEFITBENEFICIARY]
Declaration
[!DECLARATION]