Group Life, Voluntary Life, and AD&D Enrollment Form 2025

Sun Life Financial

Group Enrollment Form – Voluntary Life
Employee's Full Legal Name
(First, M.I., Last)
Date of Birth

MonthDayYear
Date
Location
Your CEI work location
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employment Type
# of hours
Hours per week
Date Employed

MonthDayYear
Hire Date
Earnings $
Indicate hourly (per hour) or annual (per year)
Dependent Information

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

Rows	Full legal name (First, M.I., Last)	Gender	Social Security number	Date of birth	Student (Y/N)
Spouse
Child
Child
Child

GROUP LIFE / AD&D – You may opt in for basic dependent life and AD&D coverage, you will only be responsible for 50% of the premium costs. This is separate from the below voluntary coverages.
Benefit Elections

You need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it. This must be done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer ("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.
Employee Voluntary Life Insurance
Employee – Voluntary Life Insurance Amount
Enter Dollar Amount $
Have you used tobacco in any form in the past 12 months?
Spouse Voluntary Life Insurance
Spouse – Voluntary Life Insurance Amount
Enter Dollar Amount $
Has your spouse used tobacco in any form in the past 12 months?
Child Voluntary Life Insurance
Child – Voluntary Life Insurance Amount
Enter Dollar Amount $
Beneficiary Designation Information

On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation is required.

*must equal 100%
Primary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary Designation

On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary.

*must equal 100%
Secondary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.

Ifapplying for coverage more than 31 days past my eligibility date, Evidence of Insurability (EOI) may be required. For Life insurance, Evidence of Insurability may be required for amounts over my Guarantee Issue for this enrollment. Increases to current Life 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, 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 (Wellesley, MA Coverages include limitations and exclusions 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.
Employee Signature
Today's Date

MonthDayYear
Date
Sun Life Financial

Group Enrollment Form – Voluntary AD&D Your employee information from the above fields will be populated here. Please take time to double-check for accuracy.
You need to complete all sections of the enrollment form including electing or refusing insurance coverage below from one of the insurance companies above, outside of New York, and sign it. This must be done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer ("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.

Voluntary AD&D Coverage; underwritten by Sun Life Assurance Company of Canada (Wellesley, MA)

Employee Coverage: Spouse Coverage: ** Child(ren) Coverage: **

** Spouse and children may only be covered if you are. You cannot elect more than 50% of the amount of Voluntary Insurance you have elected for yourself for your spouse and child(ren
Marital Status
Employee Status
Benefit Elections
Employee Coverage
Employee Coverage Amount
Enter Dollar Amount $
Spouse Coverage
Spouse Coverage Amount
Enter Dollar Amount $
Child Coverage
Child Coverage Amount
Enter Dollar Amount $
4. 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.

Full Legal Name (First, Middle Initial, Last)

5. Beneficiary Designation Information

Primary Beneficiary Designation

Voluntary AD&D Insurance - On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Primary Beneficiary(ies)

Beneficiary Designation Information

On the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as many individuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payable in accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation is required.

*must equal 100%
Primary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary Designation

On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary.

*must equal 100%
Secondary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1 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 I decline coverage for Voluntary AD&D and do not enroll when I am eligible, I will not be allowed to enroll for at least 6 months. 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. Signature of employee Date signed
Signature of employee
Date Signed

MonthDayYear
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.

By mail Sun Life Assurance Company of Canada and/or Sun Life and Health Insurance Company (U.S One Sun Life Executive Park Wellesley Hills, MA 02481

Customer Service 800-247-6875 M-F 8:00 a.m.-8:00 p.m.,

Sun Life Assurance Company of Canada and Sun Life and Health Insurance Company (U.S are members of the Sun Life Financial group of companies. 2013 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
Sun Life Assurance Company of Canada

You may use this form to designate who will receive the Group Life Insurance proceeds in the event of your death. The designations you make on this form replace any prior beneficiary designations. When applicable, designations apply to any Basic, Optional, Voluntary, Accidental Death and Dismemberment ("AD&D"), or other Group Life Insurance you have under the Group Policy shown in Section 1. See Page 3 of this form for sample beneficiary designations and more information.
Beneficiary designation

For primary beneficiaries, indicate who should receive the group life or AD&D insurance proceeds in the event of your death.For secondary, (also known as contingent) beneficiaries, indicate who should receive the group life insurance proceeds in the event that ALL of your primary beneficiaries are not living at the time of your death. Please make your beneficiary designation(s) below. If you need more space, attach another sheet to this form.You may designate more than one Primary or Secondary Beneficiary. If you do, make sure to indicate the percentage share each should receive. The total within each class (Primary and Secondary) must equal 100%. If you do not specify percentages, surviving beneficiaries within the class will share proceeds equally.
Please Note: You cannot name your Employer as a beneficiary for Group Life Insurance proceeds under the Group Policy. Unless you specifically instruct otherwise, your beneficiary designation will be revocable.

Dependent Life Insurance benefits are payable to the Employee. If the Employee does not survive the Dependent,

Dependent Life Insurance benefits will be paid to the Employee's estate.

Sun Life Assurance Company of Canada is not a tax or legal advisor and the above information is provided as general information only. Before making beneficiary designations, you may want to consult with your tax or legal advisor.

*must equal 100%
Primary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Beneficiary 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Beneficiary 4 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary Designation

On the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary.

*must equal 100%
Secondary Beneficiary 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Beneficiary 4 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee Signature
Date

MonthDayYear
Date
CEI Human Resources will retain a paper copy of your beneficiary form and will send a copy to your CEI email address; please print for your records.
Should be Empty:

Rows	Name (First, M.I., Last)	Relationship to employee	Social Security number	Phone number	Date of birth	Percent share of proceeds*
Primary Beneficiary 1
Primary Beneficiary 2

Rows	Full Legal Name (First, Middle Initial, Last)	Gender	SSN	Date of Birth	Check if elected Dep. Vol AD&D
Spouse
Child
Child
Child

Sun Life Financial

Dependent Information

Benefit Elections

Beneficiary Designation Information

Secondary Beneficiary Designation

Sun Life Financial

Benefit Elections

Beneficiary Designation Information

Secondary Beneficiary Designation

Sun Life Assurance Company of Canada

Beneficiary designation

Secondary Beneficiary Designation