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Home HSC Death Grant Nomination Form (DG3)

HSC Death Grant Nomination Form (DG3)

Please read these notes before completing the death benefit nomination form, then keep them in a safe place.

1. You may use this form only if you have scheme membership on or after 1 April 2008.

2. Any nomination will only be effective from 1 April 2008.

3. Any previous nominations you have made will be cancelled in favour of this one, and any amendments required to this nomination will need a completely new application.

4. You can nominate as many people as you like or, alternatively one organisation. Please ensure you inform us of any change of address of your nominee(s).

5. If you nominate more than one individual select either ‘equal share’ or enter the proportion, as a percentage of the total benefits each individual should receive, where indicated on the form. The total of the proportions must equal 100%.

6. An organisation must be one of the following:

  • a body corporate
  • an unincorporated body
  • your personal legal representative

7. HSC Pension Service will send you a copy of your form as confirmation of the update.

8. If you are completing this death benefit nomination in favour of your partner and want them to receive your survivor pension benefits when you die, you must also complete a ‘Partner Nomination Form’ PN1. This form is available from our website or you can ask your Employer to download a copy for you.

9. You should consider changing your death benefit nomination if your personal circumstances change. You can do this either by submitting a new application or by cancelling an existing application.

10. An individual nomination will not be valid, if at the time of your death:

  • a nominee has died; or
  • a nominee was convicted of your murder or manslaughter.

11. The Scheme must pay death benefits within two years of your death. If we are unable to trace anyone you have named, or if there is no valid nomination, we will pay any death benefit to your personal representative.

12. When you have completed your form please return it to the address at the top of the page.

Part A - To be completed by the applicant in all cases

Section 1 - Personal Details
Name(Required)
Address(Required)
DD slash MM slash YYYY

Section 2 - Nominee Details

Complete Section 2a or 2b. You cannot complete both.

Section 2A - Individual nominee details

Name
Address
DD slash MM slash YYYY

Name
Address
DD slash MM slash YYYY

Name
Address
DD slash MM slash YYYY

Name
Address
DD slash MM slash YYYY

Section 2B: Organisation or Personal Legal Representative nominee details

Contact Address

Part B - Declaration

Declaration(Required)

Part C - Witness details - must not be a relative or nominee*

Name of Witness
Address of Witness

Please get your witness to write the following statement and sign and date it. Please upload it before submitting this form.

"I certify that the above Declaration was signed in my presence by the member, whom I believe to be the person named."

Max. file size: 40 MB.

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