Enrollment Form
SunLife One Sun Life Executive Park, Wellesley Hills, MA 02481 Group Enrollment Form
Sun Life Assurance Company of Canada One Sun Life Executive Park Wellesley Hills, MA 02481
New employee
Change
COBRA
Employer use (check one):
1. General Information Employer Name Loop Recruiting, LLC
Account / Policy Number 954258
Location
2. Employee Information Employee's Full Legal Name (First, M.I., Last)
Date of Birth
Male Female
Street Address
City
State
Zip Code
Occupation
Eligibility Class (if applicable) Social Security Number Phone Number
Date employed:
Full-Time Part-Time
Date: Date:
Return from layoff Date:
Rehire
Current Active Employment Type # of hours Full-Time
Earnings $ Hourly
Part-Time
Weekly
Monthly
Annually
Other:
3. Dependent Information Please complete this entire section if you are selecting dependent coverage. No employee can be insured as a dependent when he/she is also insured as an employee for any benefit under the same policy. If more space is needed, please add additional pages. Relationship Full legal name (First, M.I., Last) Gender Social Security number Date of birth Student Y/N Spouse Children
13 LOOP RECRUITING 2023 BENEFITS GUIDE
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