Group benefits enrolment form (SunLife)

Group benefits enrolment form
Thank you for taking the time to enroll into your Group Benefits Plan with SunLife Financial!
1. COMPANY AND EMPLOYER DETAILS
COMPANY / EMPLOYER NAME*
START DATE OF EMPLOYMENT yyyymmdd*

MonthDayYear
Date
Occupation*
Pay Type:*

Annual SalaryHourly RateOther
Annual Salary or Hourly Rate *
Working hours per week *
Hours per week
2. EMPLOYEE DETAILS

Important: To be eligible for Extended Health Benefits under this plan, you must have coverage through your Provincial Medicare Plan (e.g. MSP, OHIP, RAMQ, MSP) or federal plan.
Name*

First NameLast Name
Gender*

MaleFemale
Home Mailing Address (street number and name)*
Apartment or suite*
City*
Province*
Postal code*
Date of birth (yyyy/mm/dd)*

MonthDayYear
Date
Language*

EnglishFrench
Status*

SingleMarriedCommon lawCivil Union (live with a partner, bf or gf)DivorcedSeparatedWidowed
Province of residence*
Province of employment*
Telephone Number*
If you are a resident of BC or MB please provide your Pharmacare number*
Email address (Used to sign into mysunlife.ca and manage claims)*
example@example.com
Do you live with a romantic partner?*

YESNO
Do you have dependent children under the age of 21? Or dependent children who are full-time students between ages 21 and 25?*

YESNO
Does your live-in partner/ spouse OR dependent children have coverage through their employer?*

YESNO
What is the insurance company name your partner or spouse are covered under? *
What is the plan and employee cert/ID number? *
What type of Health Plan do they have through the other plan:*

SingleFamily
What type of Dental Plan do they have through the other employer plan:*

SingleFamily
3. REFUSAL OF BENEFITS

If you or your dependents are presently covered for Extended Health Care and/or Dental Care benefits under another group contract you may refuse to be covered for such benefit(s) under this contract by selecting the applicable box for each benefit.

If you do not refuse benefits, you will be able to coordinate both plans.

Once you refuse, you may apply to rejoin without medical up to 31 days from coverage loss. If you miss this date, you will be subject to medical and even if approved, you will still be limited to $100 of Dental for the 1st year.

IF YOU WISH TO ENROL AS A FAMILY, SKIP THIS SECTION
I refuse coverage for myself and my dependents under:

Extended Health CareDental Care
I refuse coverage for my dependents ONLY under:

Extended Health CareDental Care
4. SPOUSE OR PARTNER DETAILS

If you live with a partner or have a spouse,

Complete the following section. IMPORTANT: A spouse/partner must first claim from his/her own employer's plan (if there is one). To be eligible for Extended Health Benefits under this plan, your spouse must have coverage through their Provincial Medicare plan (e.g. OHIP, RAMQ, MSP) or federal plan.
Name*

First NameLast Name
Gender*

MaleFemaleOther
Date of Birth (yyyy/mm/dd)*

MonthDayYear
Date
If your spouse is a resident of BC, AB, or MB please provide their Pharmacare number*
5. CHILDREN DETAILS

If you have dependent children, complete the following section. Due to mandatory Dependent Life coverage, you must provide children(s) name and date of birth. IMPORTANT: Claims for covered children must be sent first to the plan of the parent whose birth date falls earlier in the year.

* A student, as defined by the terms of your benefits plan (e.g. age 21 or over but under age 25), is a child who is attending an educational institution recognized by Canada Revenue Agency as a full-time student. They must not be married or in any other formal union. They must be dependent on your financial support. (For Quebec plan members, please check with your plan administrator for dependent student age limit ** To enrol an over-age disabled child, complete a Disabled Child Coverage form, and send it to us within 6 months of the date the dependent reaches the age limit.
CHILD 1 Full Name*

first name last name
Date of Birth (yyyy/mm/dd)*

MonthDayYear
Date
Gender*

MaleFemale
Are they a full-time student between ages 21 and 25?*

YesNo
Are they an over-age disabled child?*

YesNo
Do you have more children?*

YesNo
CHILD 2 Full Name*

first name last name
Date of Birth (yyyy/mm/dd)*

MonthDayYear
Date
Gender*

MaleFemale
Are they a full-time student between ages 21 and 25?*

YesNo
Are they an over-age disabled dependent child?*

YesNo
Do you have more children?

YesNo
CHILD 3 Full Name*

first name last name
Date of Birth (yyyy/mm/dd)

MonthDayYear
Date
Gender*

MaleFemale
Are they a full-time student between ages 21 and 25?*

YesNo
Are they an over-age disabled dependent child?*

YesNo
Do you have more children?

YesNo
CHILD 4 Full Name*

first name last name
Date of Birth (yyyy/mm/dd)

MonthDayYear
Date
Gender*

MaleFemale
Are they a full-time student between ages 21 and 25?*

YesNo
Are they an over-age disabled dependent child?*

YesNo
Do you have more children?*

YesNo
6. BENEFICIARY NOMINATION

Your group benefits plan has Life and Accedental Death and Dismemberment coverage. If you are nominating a child under the age of 18, you will also need to designate a Trustee.

The percentages must add up to 100%
Beneficiary*

First NameLast Name
Relationship: spouse/mother/father etc Percentage of Benefit: 100%* %
Beneficiary 2 - OPTIONAL

First NameLast Name
Relationship: Percentage of Benefit: %
Beneficiary - 3 - OPTIONAL

First NameLast Name
Relationship: Percentage of Benefit: %
(IR)REVOCABLE BENEFICIARY

If you designate an irrevocable beneficiary, then the irrevocable beneficiary's consent is required for you to either: (a) replace the irrevocable beneficiary or (b) decrease the coverage amount or the percentage of benefits payable to the irrevocable beneficiary.
Do you want the beneficiary to be revocable or irrevocable? (If you designate an irrevocable beneficiary, it may not be changed unless the beneficiary signs a form)*

Revocable (most common)Irrevocable
Are one or more of your beneficiaries under age of majority? (under 18)*

YESNO
7. APPOINTING OF TRUSTEE FOR MINOR BENEFICIARY OTHER THAN QUEBEC RESIDENTS: If a beneficiary is under the age of majority, you must designate a Trustee. Full Name of Trustee:*
Name the trusted individual who will be responsible until the child becomes of age.
APPOINTING CONTINGENT BENEFICIARY - OPTIONAL

If all beneficiaries listed above have died, please designate a contingent beneficiary:
CONTINGENT BENEFICIARY 1 - optional

First nameLast name
Relationship: Your relationship Percentage of Benefit: 100% %
CONTINGENT BENEFICIARY 2 - optional

First nameLast name
Relationship: Your relationship Percentage of Benefit: 100% %
CONTINGENT BENEFICIARY 3 - optional

First nameLast name
Relationship: Your relationship Percentage of Benefit: 100% %
9. AUTHORIZATION AND SIGNATURE

IMPORTANT!

You must sign and date the form. | am authorized to disclose information about my spouse and dependents in order to enrol them in the plan. By enrolling in this plan, I authorize Sun Life Assurance Company of Canada (Sun Life)*, its re-insurers and the plan sponsor to collect, use and disclose relevant info about me, my spouse and dependents necessary for: enrolment, payroll deductions and plan administration; underwriting coverage; adjudicating claims. *Any reference to Sun Life, its reinsurers or the plan sponsor includes their agents and service providers. | declare that the information above is accurate and true. Inaccurate information may invalidate a claim. Where permitted by law, the beneficiaries named here replace all previous beneficiary nominations. A photocopy or electronic version of this signed form is valid. The original is still required for beneficiary nominations.
Plan member signature*

Clear
Date yyyymmdd*

MonthDayYear
Date
10. RESPECTING YOUR PRIVACY

Our Purpose is to help our Clients achieve lifetime financial security and live healthier lives. We collect, use and disclose your personal information to: develop and deliver the right products and services; enhance your experience and manage our business operations; perform underwriting, administration and claims adjudication; protect against fraud, errors or misrepresentations; tell you about other products and services; and meet legal and security obligations. We collect it directly from you, when you use our products and services, and from other sources. We keep your information confidential and only as long as needed. People who may access it include our employees, distribution partners such as advisors, service providers, reinsurers, or anyone else you authorize. At times, unless we're prohibited, they may be outside your jurisdiction and your information may be subject to local laws. You can always ask for your information and to correct it if needed. In most cases, you have a right to withdraw your consent, but we may not be able to provide the requested product or service. Read our Global Privacy Statement and local policy at www.sunlife.ca/privacy or call us for a copy.

You have a choice:

We will occasionally inform you of other financial products and services that we believe meet your changing needs. If you do not wish to receive these offers, let us know by calling 1-877-SUN-LIFE (1-877-786-5433).
Should be Empty:

Group benefits enrolment form

Thank you for taking the time to enroll into your Group Benefits Plan with SunLife Financial!