Sun Life Enrollment Application
6 |Signature and authorization information I understand that: •
I am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when my employment terminates, subject to any portability or continuation provisions available under the Group Insurance policy. • My employer will deduct all or part of the premium for contributory coverage from my pay. • If applying for coverage more than 31 days past my eligibility date, Evidence of Insurability (EOI) may be required. • For Cancer insurance, Evidence of Insurability will be required for amounts over my Guarantee Issue for this enrollment. • Increases to current Cancer benefits may require Evidence of Insurability. • If I decline coverage for myself or, if applicable, for my family now and want it at a later date, I/we will have to submit an Evidence of Insurability application, if required for the elected coverage(s), to be approved by Sun Life Assurance Company of Canada. • Coverages include benefit waiting periods, limitations, and exclusions and a pre-existing conditions provision that may affect my entitlement to benefits. • If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date I return to work. • When required by the coverage, if my spouse or any of my dependent children are confined due to an injury or illness, as required by the coverage, on the date that any initial or increased coverage is scheduled to start under the plan, such coverage will not start until the date they are no longer confined and are able to perform their normal activities. By signing below, I am representing that the information I have provided is true and correct to the best of my knowledge and belief. X Employee Signature Today’s Date To the Employee : Make a copy of this form for your records before submitting it to your employer. To the Employer: This original enrollment form should remain at the employer’s site. Family status, coverage, or beneficiary changes should be recorded on another copy of the Enrollment form.
Agent, Broker, and/or Enroller information: Agent name Agent / Broker name Enroller name
Contact us By mail
Sun Life Financial One Sun Life Executive Park Wellesley Hills, MA 02481 www.sunlife.com/us
Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET
. GVMPEM-5627
Group Enrollment Form Page 3 of 3
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25 STERLING ESTATES 2023 BENEFITS GUIDE
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