Government of Ontario: Financial Services Commission of Ontario

Form 4 - Waiver of Pre-retirement Death Benefit

Approved pursuant to the Ontario Pension Benefits Act
(R.S.O. 1990, c. P.8, as amended)

Send this form to the plan administrator or the insurer
Do not send it to the Financial Services Commission of Ontario


Name of spouse of member or former member

I, am or was the spouse, within the meaning of the Pension Benefits Act, of


Name of member or former member

, who is or was entitled to a pension benefit under the


Name of pension plan

. (referred to below as the “pension plan”)

I understand that section 48 of the Pension Benefits Act provides that if my spouse dies,

  1. before payment of the first instalment of his or her deferred pension or pension is due; or
  2. where my spouse continues in his or her employment after the normal retirement date, prior to the commencement of payment of pension benefits,

then I am entitled to receive a pre-retirement death benefit of either a lump sum payment or an immediate or deferred pension from the pension plan at the date of my spouse’s death if I am not living separate and apart from my spouse at that time.

I understand that I may waive my right to receive any pre-retirement death benefit by signing this waiver.

I understand that if I sign this waiver, I will not be paid any pre-retirement death benefit provided by section 48 of the Pension Benefits Act. Instead, payment of this benefit will be made to either,

  1. a beneficiary designated by my spouse; or
  2. the personal representative of my spouse for distribution as part of his or her estate.

I hereby waive my right to receive any pre-retirement death benefit provided by section 48 of the Pension Benefits Act by signing this waiver in the presence of a witness.

I understand that I may cancel this waiver at any time prior to the date of my spouse’s death.

Day, Month, Year

, .



Witness Information



NOTE: Prior to completing this form, each party should consider obtaining independent legal advice concerning their individual rights and the effect of this waiver.

NOTE: This waiver is not effective unless it is delivered to the administrator of the pension plan as required by subsection 48(14) of the Pension Benefits Act.