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Rustee appointment dated and signed on , 201 . References to the Issuer in this form may include London Life Insurance, The Canada Life Assurance Company and/or The Great-West Life Assurance Company, as applicable. EMPLOYER/PLAN SPONSOR INFORMATION Name of employer/plan sponsor Policy/plan number(s) MEMBER INFORMATION (please print) Last name Initial First name Certificate/Social insurance number This beneficiary designation and/or trustee appointment will apply to: All retirement, saving.

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