Application for conversion and exercising an option

Transcription

1 Application for conversion and exercising an option Instructions and advisor s report Section Page Application for conversion and exercising an option General information Beneficiary information Plan details Sun Par Protector and Sun Par Accumulator additional information. 6 5 SunUniversalLife and SunUniversalLife MAX additional information. 6 6 Sun Limited Pay Life additional information. 8 7 Acknowledgement of variability Identity verification/third party determination/ politically exposed foreign person (PEFP)/source of payment Additional evidence Child(ren) to be insured under a Child term benefit (CTB) Payments Acknowledgement and agreement Advisor s report Licensed administrative assistant s declaration. 18 Advisor instructions Use this application if: applying for conversion, group conversion or exercising an option (without an increase in coverage) of all eligible Sun Life Financial life insurance products offered by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies, or applying for conversion or exercising an option (without an increase in coverage) and only adding ROPD, Plus premium or Child term benefit. Please give page 19, containing the Sun Life Financial Privacy Statement for Canada to the proposed insured. Important information you should know Page 1 of 19 Information page only do not submit with application.

2 Application for conversion and exercising an option This is a conversion from an: Please PRINT clearly Individual policy # Group policy/certificate # Other eligible policy # (specify) In this application, I, you and your refer to the proposed insured and the applicant. We, us, our and the company refer to Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. 1 General information Information about the proposed insured (Provide Social Insurance Number (SIN) only if proposed insured is also an applicant.) Note: If the mailing address differs from the residential address, provide details in the Advisor s report. In the chart below, you refers to the proposed insured. First name Middle initial Last name Male Female Former surname (if any) Place of birth (city) Place of birth (country) Date of birth (dd-mm-yyyy) Residential address (street number and name) Apartment or suite City Province Country Postal code SIN (required for tax reporting for life insurance) Driver s licence number Province Occupation (specify job title) Occupation (specify job duties) Home phone number Name of employer Address of employer (street number and name) City Province Postal code Business phone number If you are also an applicant and are applying for universal or permanent life insurance, the following question must be answered. Are you a U.S resident for tax purposes (which includes a U.S citizen)? Yes No Does the applicant want to retain age?m Yes m No Note: Age may be retained up to 90 days. If yes, provide a U.S Taxpayer Identification Number (TIN). Proof of age (Complete only if not provided on the original application.) Document (indicate type) Canadian, USA or UK driver s license Canadian, USA or UK birth certificate Canadian citizenship Indian status card Current valid Canadian passport Current valid passport, other than Canada Baptismal certificate Hospital certificate of birth Register of civil status in Quebec Provincial identification card Military card Current Nexus card Provincial ID health insurance card (if date of birth is indicated) Includes: RAMQ, Medicare and BC medical care card (may say MSP card) Requirement Registration number Expiry date (dd-mm-yyyy) Issue date (dd-mm-yyyy) Expiry date (dd-mm-yyyy) OR Registration number Permanent resident card Expiry date (dd-mm-yyyy) OR ID number AAPPE Page 2 of 19 Please submit only one copy of this document. Career Sales Force advisors: Original or fax toll-free to All others: Through your MGA or National Account.

3 1 General information (continued) Information about the applicant (Complete if the applicant is not the proposed insured.) Note: Also enter ID information in section 8 if applying for universal or permanent life insurance. In the chart below, you refers to the applicant. First name Middle initial Last name Male Female Date of birth (dd-mm-yyyy) Occupation Residential address (street number and name) Apartment or suite City Province Country Postal code SIN (required for tax reporting for life insurance) Relationship to the proposed insured If you are applying for universal or permanent life insurance, the following question must be answered. Are you a U.S resident for tax purposes (which includes a U.S citizen)? Yes No If yes, provide a U.S Taxpayer Identification Number (TIN). Corporate or joint applicant (Complete if the policy is owned by a corporation, or if there is a joint applicant who is not being insured.) Notes: Also enter ID information in section 8 if applying for universal or permanent life insurance. For a joint applicant, provide their Social Insurance Number and relationship to the proposed insured. First name or Corporation name Middle initial Last name Mailing address (street number and name) Apartment or suite City Province Country Postal code Business/occupation Date of birth (dd-mm-yyyy) Contingent owner Complete if one owner and the policy will continue after the owner s death (where owner is not the insured person). Complete if more than one applicant: Multiple owners outside Quebec If this policy is owned by more than one person, and an owner dies, their interest will pass in equal shares to the surviving owners unless a contingent owner is named for them. If, on the death of any owner, that deceased owner s interest is to pass to a named contingent owner, then the name of the contingent owner must be completed in the space provided below next to the applicable owner s name. Multiple owners in Quebec Survivorship provisions do not apply in Quebec. If one of the owners die, their interest in the policy will pass to the contingent owner named below. The surviving owner will continue to own their interest in the policy. Indicate the name of the applicant (owner) and their contingent owner in the space provided below. Applicant (owner) Contingent owner Relationship to the applicant (owner) Applicant (owner) Contingent owner Relationship to the applicant (owner) 2 Beneficiary information In this section, you and your refer to the applicant. Note: For Joint last-to-die, complete the form SunUniversalLife or SunUniversalLife MAX Early death benefit beneficiary election and/or change Joint last-to-die coverage (policy value only) (E272): for SunUniversalLife and SunUniversalLife MAX with the Insurance amount plus fund or Fund builder option, or for Sun Limited Pay Life with minimum guaranteed death benefit of $250,000. Page 3 of 19

4 2 Beneficiary information (continued) a) Primary beneficiaries (Share of benefits must add up to 100%.) Notes: If not completed, the beneficiary will be the applicant or the estate of the applicant. In Quebec, the share of the predeceasing beneficiary will pass on to the surviving beneficiary(ies) of the same level, only if you have designated beneficiaries to receive death benefits in equal shares. In cases of unequal shares, the predeceased beneficiary s share will revert to your estate or to the secondary level of beneficiary(ies) if designated. In Quebec, if you name your legal spouse (by marriage or civil union) as the beneficiary, this designation will be irrevocable unless you check the Revocable box in a) and b) below. First name Middle initial Last name b) Contingent beneficiaries (Share of benefits must add up to 100%.) First name Middle initial Last name Relationship to proposed insured (In Quebec, relationship to applicant) Relationship to proposed insured (In Quebec, relationship to applicant) Beneficiary designation m Revocable m Irrevocable m Revocable m Irrevocable Beneficiary designation m Revocable m Irrevocable m Revocable m Irrevocable % share of benefits to be paid % share of benefits to be paid Total 100 % Total 100 % c) Trustee for a minor beneficiary (Complete when a minor beneficiary has been named in beneficiary designations (a) - (b).) In all provinces other than Quebec, if you designate minor children as beneficiaries, you should also name a trustee to receive funds on their behalf. In Quebec, any amount payable to a minor beneficiary during their minority will be paid to the parent(s) or legal guardian of the minor child. i) Primary beneficiaries: I appoint ii) Contingent beneficiaries: I appoint as a trustee to receive any payments on behalf of any named minor beneficiary, during their minority. The trustee may apply such payments solely for the support, maintenance, education and benefit of such beneficiary at the discretion of the trustee. 3 Plan details In this section, your refers to the applicant. Complete for all applications. Note: The following questions must be answered by the proposed insured. If proposed insured is under age 16 (18 in Quebec), the questions must be answered by the parent or legal guardian. 1. In the last 12 months, has the proposed insured smoked or used cigarettes, cigarillos, small or large cigars, pipes, marijuana, hashish, betelnut, chewing tobacco, nicotine gum or patches, or nicotine or tobacco in any other form... m Yes m No 2. Is the proposed insured currently disabled or claiming on their disability benefit on any of their policies?... Yes m No If yes, indicate policy no.: (, ) Complete for conversions only: Notes: All conversions must meet current product minimums and meet all product and benefit availability guidelines. For any amount of insurance in addition to the amount available for conversion, a new application for life or critical illness insurance must be completed. If converting from universal life, only the fund in excess of the surrender charges will be transferred to the new policy. If only applying for a change to the smoking status of your policy, complete the Declaration of smoking status form (E18) instead of this application. Conversion of: m Term plan m Sun Limited Pay Life m Group plan m Critical Illness m Single life m Benefits m Enhancement m Universal life coverage m Joint first-to-die m Joint last-to-die m Other m Convert the full amount or m Partial conversion amount to be converted $ amount not to be converted is to: m remain in-force m be cancelled or m New basic insurance amount$ Page 4 of 19

5 3 Plan details (continued) Convert to: m Sun Par Protector $ or m Sun Par Accumulator $ m 20 pay m 20 pay m Paid-up at age 65 m Life Pay (to age 100) m Life Pay (to age 100) Note: Section 4 must also be completed. m SunUniversalLife or m SunUniversalLife MAX (Section 5 must also be completed.) Cost of insurance:m Guaranteed yearly term or m Guaranteed level term or m Sun Limited Pay Life (Section 6 must also be completed.) m 10 year m 15 year m 20 year m Pay to age 65 (Only available on single life.) or or or m SunLifetimeAlternative m Sun One year term (Only available on group conversions.) m Sun Term to 65 (Only available on group conversions.) or m Sun Critical Illness Insurance m Term 75 m Lifetime Guaranteed payment period Guaranteed payment period m 15 years m To age 75 m 10 years m 15 years m To age 100 or m Existing policy #: or Benefits details: m Other / benefit: m Keep all the policy benefits that are available for conversion m Delete all existing policy benefits m Keep these benefits only (describe): m Return of premium benefit(s): m ROPC m ROPD Note: If ROPD is not on the original contract, section 9 must also be completed. m Enhancement $ (Check one.)m Lifetime Complete for group conversions only: Note: Include a copy of the client s termination notice with this application. m 10 Year Guarantee Group company name Group policy number Eligible amount Date the group insurance was terminated, the last day worked or the benefit s expiry date: (dd-mm-yyyy) Is this a spousal conversion? m Yes m No. If yes, complete the following spousal information: Spouse s first name Last name SIN (required for tax reporting for life insurance) Date of birth (dd-mm-yyyy) Ensure spouse signs on page 17. Complete for exercising options only: Indicate the type of option being exercised: Guaranteed insurability Child term Spousal term Business value protection, or Partner protection. Amount of option being exercised $ Eligibility relates to the person being insured: m Age m Date of first marriage (dd-mm-yyyy) m Child s date of birth (dd-mm-yyyy) m Date of legal adoption (dd-mm-yyyy) m Other $ Page 5 of 19

6 4 Sun Par Protector and Sun Par Accumulator additional information In this section, you and your refer to the applicant. Note: Complete this section only if you are applying for a new Sun Par Protector or Sun Par Accumulator insurance policy. a) m Single Life m Joint first-to-die m Joint last-to-die m premiums payable to first death m premiums payable to last death b) Dividend options m Paid-up additional insurance (PUA) Note: If PUA, section 9 must also be completed. m Annual premium reduction (Only available if premiums are payable on an annual basis.) m Cash payment m Dividends on deposit m Enhanced insurance (Only available on Sun Par Protector.) Basic amount $ Enhanced amount $ Choose one: m 10 year guarantee m Lifetime guarantee Total (Basic + Enhanced) $ c) m Plus premium benefit (PPB) Payment option for PPB m Scheduled (regular monthly or annual payments): m Monthly $ m Annual $ m Single payment (one-time purchase) $ d) Premium offset Do you want us to notify you if and when the policy you applied for may become eligible for premium offset?... m Yes m No Premium offset is an administrative feature (not a contractual right under the policy) that may allow you to use dividends and accumulated value within the policy to help pay future premiums if certain conditions are met. The premium offset date is not guaranteed. It may occur sooner or later, or not at all, depending on future dividend scale changes. If and when the policy goes on premium offset, at some point you may have to resume out-of-pocket premium payments. e) Request to receive mailing Upon issuance of the policy, you will have the right to attend and to vote in person or by proxy at meetings of the voting policyholders of Sun Life Assurance Company of Canada. Do you want to receive notice of these meetings and related information? m Yes m No If not completed, we will assume response as yes. 5 SunUniversalLife or SunUniversalLife MAX additional information In this section, you and your refer to the applicant. Notes: Complete this section only if you are applying for a new SunUniversalLife or SunUniversalLife Max insurance policy. If an investment mix change is required on an existing universal life policy, complete a Universal Life Client service request form. a) Death benefit options Choose one of the following: l Level insurance amount l Indexed insurance amount (Check one.) l at % per year (specify between 1% and 8%, in multiples of 0.25%) l at the annual rate of Canada s Consumer Price Index (to a maximum of 8% per year) l Insurance amount plus your policy fund value For multiple life coverage, the fund value will be paid as a proportion of each insurance amount to the total, unless you tell us your fund value is to be paid with thel first or l last settlement of basic benefits under the policy. l Fund builder Fund builder is a variation of the Insurance amount plus fund option. It is not available in Bermuda. Starting with the policy anniversary, the insurance amount will be reduced annually to the lowest level that maintains your policy s tax-exempt status. Stop annual reductions when the insurance amount reaches $ b) Investment bonus (Must be indicated.) l Yes l No Page 6 of 19

7 5 SunUniversalLife or SunUniversalLife MAX additional information (continued) c) Investment account options You must allocate your payments to any of the following Investment account options. Your choices must be in multiples of 5% and they must add up to 100%. Each of your investment accounts must also have a minimum amount of $ If you have selected an Investment account option which is no longer available but is not reflected in this application, we will allocate your selection to the Daily interest account (DIA). We ll tell you what options are then available for you to make an alternative selection. You can tell us which option you want to use in place of the option that s no longer available. Interest rate accounts Daily interest account Guaranteed interest accounts (GIAs) 1 year 3 year 5 year 10 year 20 year Percentage Accounts based on indices Percentage American Equity American Technology* Canadian Bond Canadian Equity European Equity* Foreign Equity FPX Balanced* FPX Growth* FPX Income* Japanese Equity* Pacific Equity* * Investment account options are not available in Bermuda. Accounts based on managed funds CI Portfolio Series Balanced CI Portfolio Series Conservative CI Canadian Investment CI Global CI Portfolio Series Balanced Growth CI Portfolio Series Conservative Balanced CI Harbour CI Harbour Growth & Income CI Signature High Income CI Signature Income & Growth Cambridge American Equity Corp Class Fidelity U.S. Focused Stock Fidelity Global Fidelity NorthStar Fidelity True North Mackenzie Cundill Canadian Balanced Mackenzie Cundill Value Mackenzie Ivy Foreign Equity Sun Life MFS US Equity Sun Life MFS Balanced Growth Sun Life MFS Canadian Equity Value PHN Balanced PHN Bond PHN Canadian Equity PHN Dividend Income Sub total % + Sub total % + Sub total % = 100% Your GIA earnings will automatically compound until the account matures. On maturity, your GIA account balances will automatically transfer to the Activity account unless you check this box: l Rollover to a new account of the same term Percentage In what order do you want your investment account withdrawals and transfers processed? If not specified, your withdrawal order will be Proportional. (A change to this section is not available after the policy is issued. Check one.) l Standard order: or Activity account Daily interest account Accounts based on the performance of indices Accounts based on the performance of managed funds GIAs (nearest to maturity) l Alternative order: or Activity account Daily interest account GIAs (nearest to maturity) l Proportional order: Activity account Proportional across all options Page 7 of 19

8 5 SunUniversalLife or SunUniversalLife MAX additional information (continued) d) Maintaining your policy s tax-exempt status Notes: If this application is being signed in Bermuda, do not complete this section on tax-exempt status. Do not check a box if you ve chosen Fund builder death benefit. Check one of the boxes below: l Retain insurance amount l Increase insurance amount as required (to a maximum of 8%) but reverse the increase when this can be done without losing tax-exempt status (note the cost of insurance will be changed accordingly) l Increase insurance amount as required (to a maximum of 8% and the cost of insurance will be increased accordingly), but do not reverse the increase. In addition, check one box below to tell us what we should do with excess funds. (Designate a service account for any excess funds.) l Refund them to the policy owner l Transfer them to a service account which you may choose as any one of the Investment account options available under this policy (See Investment account options.) Name of Investment account option for service account 6 Sun Limited Pay Life additional information In this section, you and your refer to the applicant. a) Investment account options Note: Sun Limited Pay Life is not available in Bermuda. You must allocate your payments to any of the following Investment account options. Your choices must be in multiples of 5% and they must add up to 100%. Each of your investment accounts must also have a minimum amount of $ Interest rate accounts Daily interest account Guaranteed interest accounts (GIAs) 1 year 3 year 5 year 10 year 20 year Long Term Managed Portfolio Percentage Accounts based on indices American Equity Canadian Bond Canadian Equity FPX Balanced FPX Growth FPX Income Percentage Accounts based on managed funds CI Harbour CI Harbour Growth & Income CI Portfolio Series Balanced CI Portfolio Series Conservative CI Signature Income & Growth Fidelity North Star Fidelity True North Mackenzie Cundill Value Mackenzie Ivy Foreign Equity Sun Life MFS US Equity Percentage Sub total % + Sub total % + Sub total % = 100% Your GIA earnings will automatically compound until the account matures. On maturity, your GIA account balances will automatically transfer to the Activity account unless you check this box: l Rollover to a new account of the same term In what order do you want your investment account withdrawals and transfers processed? If not specified, your withdrawal order will be Proportional. (A change to this section is not available after the policy is issued. Check one.) m Standard order: or Daily interest account Accounts based on the performance of indices in this order: FPX Income, FPX Balanced, FPX Growth, Canadian Equity, American Equity, Canada Bond Accounts based on the performance of managed funds in proportion to the balance of each of those accounts GIAs (nearest to maturity) Long Term Managed Portfolio m Alternative order: or Daily interest account GIAs (nearest to maturity) Accounts based on the performance of indices in this order: FPX Income, FPX Balanced, FPX Growth, Canadian Equity, American Equity, Canada Bond Accounts based on the performance of managed funds in proportion to the balance of each of those accounts Long Term Managed Portfolio m Proportional order: Activity account Proportional per account balance Page 8 of 19

9 6 Sun Limited Pay Life additional information (continued) b) Maintaining your policy s tax-exempt status (Designate a service account for any excess funds.) Check one box below to tell us what we should do with excess funds. l Refund them to the policy owner l Transfer them to a service account which you may choose as any one of the Investment account options available under this policy, excluding Long Term Managed Portfolio (See Investment account options.) Name of Investment account option for service account 7 Acknowledgement of variability In this section, I refers to the applicant. I acknowledge there are many variables that can affect an insurance policy s performance, including the following (where applicable): the type of and future investment performance of the Investment account option(s) selected the future investment performance of the participating account future dividend scales the timing and amount of future deposits to and withdrawals from the policy the cost of insurance mortality and morbidity rates, lapse rates and expenses policy loans, and future federal income tax rules and provincial income and premium taxes. More specifically, I understand interest rates, future dividend scales, and the performance of securities markets in particular can fluctuate significantly and that even a small change in any one of these variables could have a dramatic negative or positive impact on the policy s non-guaranteed benefits and values. I understand that past performance does not predict nor is it a good indicator of future results. I acknowledge that any illustrations shown to me in connection with the sale of the policy will not become part of the policy and were provided solely to show me how policy values may change over time based on different sets of assumptions. I understand that, unless indicated as Guaranteed, the benefits and values in an illustration are not guaranteed, are hypothetical only and are based on assumptions that are certain to change. I realize they are neither an estimate nor a guarantee of future policy performance. I understand actual results will differ upward or downward from those illustrated, because they are highly dependent upon a number of variables (including those listed above) and that even a small change in any one of these variables could have a dramatic negative or positive impact on the non-guaranteed figures shown in an illustration. Page 9 of 19

10 8 Identity verification, third party determination and politically exposed foreign person (PEFP) Notes: In this section, you and your refer to the applicant(s). The questions must be answered by the applicant(s) of the application. Completion is mandatory on all universal and permanent life applications. If any applicant is not an individual (ie. Corporation or other entity), the following must be completed for that applicant: form 4104 (Identity verification, third party determination and politically exposed foreign person (PEFP), and form 4545 (International tax classification for an entity). Always verify the identity of clients and find out whether any third parties are involved. This helps Sun Life Financial to manage risk and to comply with the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and other relevant legislation/regulations. If additional space is required for any part of this section, complete form 4104 for each applicant. If you have completed form 4104, indicate how many have been completed for this application: Applicant s first name Middle initial Last name Date of birth (dd-mm-yyyy) Type of document Document number Province of issue Country of issue Detailed occupation/principal business Residential address (street number and name) City Province Country Postal code Applicant s first name Middle initial Last name Date of birth (dd-mm-yyyy) Type of document Document number Province of issue Country of issue Detailed occupation/principal business Residential address (street number and name) City Province Country Postal code 8.1 Is the contract to be paid for by a third party or used by or on behalf of a third party?m Yes m No Note: Types of a third party include but are not limited to: Payor Attorney (Power of Attorney) or Mandatary Collateral Assignee/Hypothecary Creditor First name Middle initial Last name Date of birth (dd-mm-yyyy) Relationship to applicant/owner Detailed occupation/principal business Type of third party Residential address (street number and name) City Province Country Postal code If a corporation, registration number Province of incorporation Country of incorporation First name Middle initial Last name Date of birth (dd-mm-yyyy) Relationship to applicant/owner Detailed occupation/principal business Type of third party Residential address (street number and name) City Province Country Postal code If a corporation, registration number Province of incorporation Country of incorporation PIVERIDE Page 10 of 19

11 8 Identity verification, third party determination and politically exposed foreign person (PEFP) (continued). If unable to obtain any required information for any third party, give details as to why below. 8.2 To the best of the applicant s knowledge, has the applicant or any close relative (living or deceased), ever held any of the following positions or offices in or on behalf of a country other than Canada? m Yes m No 1. head of state 2. head of government 3. member of the executive council of government 4. member of legislature 5. deputy minister (or equivalent rank) in government 6. ambassador 7. counsellor of an ambassador 8. attaché 9. military officer with a rank of general or above 10. president (head) of state-owned company 11. president (head) of a state-owned bank 12. head of a government agency 13. judge of a supreme court, constitutional court or other court of last resort 14. leader (or president) of a political party represented in a legislature Note: Close relative means spouse, civil union spouse or common-law partner, children/step-children, siblings/half siblings/step-siblings of the proposed owner, biological/adoptive/step-parent of the proposed owner, biological/adoptive/step-parent of spouse, civil union spouse or common-law partner. Applicant s first name Middle initial Last name First name (PEFP) 1 Middle initial Last name Relationship to the applicant Position held (indicate all applicable #s from list) Country where position held (PEFP) 2 (PEFP) Provide the source of payment for this application (Select all that apply.) m salary or earned income m applicant s savings m business income m existing investment account m pension income m gifted funds m proceeds from death benefits or estate m sale of property m inherited funds m social benefits m borrowed funds (give details in box below) m other (give details in the box below) 8.4 What is the purpose and intended use of the product applied for? m income replacement m mortgage protection m creditor protection m asset protection m estate protection m business protection m charitable donation m tax or estate planning m other (give details below) Page 11 of 19

12 9 Additional evidence In this section, you refers to the applicant. Note: The following must be answered: if you are adding the ROPD benefit to a Sun Critical Illness product, if converting to paid up additional insurance or enhanced insurance that exceeds the maximum insurance amounts, if converting to paid up additional insurance or enhanced insurance, where the original policy (converting policy) exceeds the maximum insurance amounts, if adding the Plus premium benefit at time of conversion, regardless of the face amount, if you are adding a Child term benefit, and by the proposed insured or if under age 16 (18 in Quebec), by the parent or legal guardian. 1) Has the proposed insured ever been treated for or had any symptoms or indication of: i) heart attack or any other heart disease or disorder, stroke/tia, cancer or any other growth(s) or malignancy, diabetes or kidney, lung or liver disease or disorder... m Yes ii) AIDS, HIV infection or any other disease or disorder of the immune system... m Yes 2) Is the proposed insured aware of any symptoms for which they have not yet consulted a physician or received treatment?... m Yes 3) Has the proposed insured ever had any medical conditions, not already mentioned, for which they have been or are being investigated, under observation or treated for, or for which they are currently awaiting investigation or test results?... m Yes 4) Has the proposed insured ever had any applications for life, disability, critical illness or long term care insurance declined, rated, postponed, cancelled or modified in any way?... m Yes Give details for all yes answers to questions 1, 2, 3 and 4. If more space is required, use a separate sheet signed and dated by the proposed insured. Question number Details Evidence no. (for H.O use only) E# m No m No m No m No m No EAPPE Page 12 of 19

13 10 Child(ren) to be insured under a child term benefit Note: Complete this section only if you are applying for a child term benefit (CTB). In this section, you refers to the proposed insured. The proposed insured may cover their biological, adopted or step-children under a child term benefit. Provide the following information for each child to be insured under this benefit. Child First name Middle initial Last name Do all of the listed children live with you? m Yes m No If no, complete the following. Relationship to proposed insured m child m step-child m adopted child m child m step-child m adopted child m child m step-child m adopted child m child m step-child m adopted child m child m step-child m adopted child Sex Evidence no. (for H.O use only) E# Date of birth (dd-mm-yyyy) m Male m Female m Male m Female m Male m Female m Male m Female m Male m Female First name of person the child lives with Middle initial Last name Relationship to child Child 1 Residential address (street number and name) Apartment or suite City Province Postal code First name of person the child lives with Middle initial Last name Relationship to child Child 2 Residential address (street number and name) Apartment or suite City Province Postal code First name of person the child lives with Middle initial Last name Relationship to child Child 3 Residential address (street number and name) Apartment or suite City Province Postal code First name of person the child lives with Middle initial Last name Relationship to child Child 4 Residential address (street number and name) Apartment or suite City Province Postal code First name of person the child lives with Middle initial Last name Relationship to child Child 5 Residential address (street number and name) Apartment or suite City Province Postal code Does the proposed insured have full knowledge of each child s medical history?... m Yes If no, is the person who has the most knowledge of the medical history of the children present?... m Yes Note: If not present, this benefit may not be applied for at this time. If yes, provide the name and relationship of the person answering the questions on behalf of the children. Name of person answering questions Relationship to the children m No m No Page 13 of 19

14 10 Child(ren) to be insured under a child term benefit (continued) Has any application for insurance on any of the children ever been declined, rated or modified in any way?... m Yes 1. Has any child ever been treated for or had any symptoms or indication of: a) heart murmur or any other disease or disorder of the heart or blood vessels... m Yes m No b) cancer, leukemia or any other growths or malignancy... m Yes m No c) diabetes or any other thyroid or endocrine disease or disorder... m Yes m No d) hemophilia, bleeding disorder or any other blood disease or disorder... m Yes m No e) Crohn s disease, ulcerative colitis, hepatitis or any other disease or disorder of the bowel, stomach or liver... m Yes m No f) asthma, cystic fibrosis, tuberculosis or any other respiratory disease or disorder... m Yes m No g) depression, anxiety, attention deficit disorder or any other psychological, emotional or nervous disease or disorder... m Yes m No h) disease or disorder of the kidney or urinary tract... m Yes m No i) muscular dystrophy, multiple sclerosis or any other neurological disease or disorder... m Yes m No j) Down syndrome, developmental delay, autism, cerebral palsy or any other congenital disease or disorder... m Yes m No k) epilepsy, seizure or any other disease or disorder of the brain... m Yes m No 2. Has any child ever been tested for exposure to the HIV (AIDS) virus?... m Yes m No 3. Are there any medical conditions, not already mentioned, for which any child had or is awaiting investigation, treatment or is under observation? (Exclude routine check-ups where no follow-up is required, colds, flu, tonsillectomy, adenoidectomy, appendectomy, hernia repair and tubes in ears.)... m Yes If yes to any questions in 1-3, provide details below. Child 1 Question number(s) Details Evidence no. (for H.O use only) E# m No m No Child 2 Child 3 Child 4 Child 5 Page 14 of 19

15 11 Payments 1. Method of payment information Notes: We do not accept cash payments. If a method of payment is not selected, we will proceed on a Payment on delivery basis and we assume PAC with payment instruction will be provided on delivery. Payments will not be taken from the payor s account until the policy is in effect unless initial payment in section 2 has been selected. Pre-authorized chequing (PAC) m Yes m No If yes, complete section 2. Notes: If all payors do not agree to all of the terms of the PAC authorization in section 2, PAC may not be used. We will withdraw all payments, including the initial payment, from the account shown in section 2. Annual m Yes m No If yes, submit the total annual payment to the advisor at the time the application is completed. Make the cheque payable to Sun Life Assurance Company of Canada. $ Amount paid to advisor with application. Payment on delivery m Yes m No If yes, indicate how initial payment will be made: m cheque on delivery for full annual payment m cheque on delivery for initial monthly payment with subsequent payments based on PAC information provided in section 2 below m PAC withdrawal based on PAC information provided in section 2 below, or m PAC withdrawal with PAC information/payment instructions to be provided on delivery Future periodic payment information 2. Pre-authorized chequing (PAC) authorization $ Complete for universal and Sun Limited Pay Life applications. Note: All PAC payors must agree to the following terms in order to use the PAC payment option. All PAC payors agree: Sun Life Assurance Company of Canada (company) may make deductions, at any time, for regular recurring payments and/or one-time payments from time to time, from their bank account indicated in this application for insurance, all pre-authorized debits be processed as personal under the Canadian Payments Association rules (this means having 90 calendar days from the date any payment is processed to claim reimbursement for any unauthorized payment), the withdrawal amount is considered variable under the Canadian Payments Association rules, any notices to be sent to them under this agreement may be sent to the applicant/owner s most recent address that the company has on record at the time a notice is sent, the company may charge a fee and may cancel the PAC for any withdrawal that is not honoured, all persons whose signatures are required to sign on the bank account indicated below have signed section 12 as a PAC payor, the company may not assign this authorization to another company or person in order to permit them to debit the PAC payor s account for these payments (e.g. where there has been a change in control of the company), without providing at least 10 days prior written notice, and to waive the requirement that the company notify them of: this authorization before the first payment is processed any subsequent payments, and any changes to the amount or date of the payment initiated by them or the company. a) Withdraw funds to pay the initial paymentm Yes m No (If yes, complete b) or c). We will immediately withdraw 1/12th of the annual payment as the initial payment. If no, submit the total initial payment to the advisor at the time the application is completed.) b) Start a new PACm Yes m No (If yes complete d) and e). Regular PAC withdrawals for this policy will start one month from the policy date, unless otherwise indicated in d).) PAPRSIGE Page 15 of 19

16 11 Payments (continued) c) Add to existing PAC that is paying for policy m Yes m No (Regular PAC withdrawals for this policy will be withdrawn on the same day each month as the existing PAC for the policy number listed above, unless otherwise indicated in d).) d) Sun Life Assurance Company of Canada will withdraw funds to pay all payments, including the initial payment if selected, on this policy each month from the bank account shown on the sample cheque attached or any account designated. All persons whose signatures are required to sign on this account must sign the authorization on page 17. For a joint account requiring more than one signature to withdraw funds, all the account holders must sign the authorization on page 17. We will withdraw the initial payment immediately. Regular PAC withdrawals will start one month from the policy date or on (dd-mm-yyyy). The payor may cancel this authorization at any time, subject to providing the company with 10 days notice. Payors should contact their financial institution about their rights regarding cancellation. A sample cancellation form is available at Payors have certain recourse rights if any debit does not comply with this agreement. For example, payors have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAC Agreement. To obtain more information on recourse rights, payors should contact their financial institution or visit Contact us at any time at: Sun Life Assurance Company of Canada 227 King Street South PO Box 1601 Stn Waterloo Waterloo, ON N2J 4C SUN-LIFE ( ) Fax # e) Attach a sample cheque marked void OR complete the following: (Only accounts with chequing privileges may be used.) Account holder s first name Last name Account holder s first name Last name Name of financial institution Address of financial institution (street number and name) City Province Postal code Transit number Account number Page 16 of 19

17 12 Acknowledgement and agreement Acknowledgement and agreement The applicants confirm they ve received, read and agree to the guide to critical illness definitions, if critical illness insurance was applied for. The applicants and proposed insureds (if other than applicant) confirm they ve received, read and agree to the Sun Life Financial Privacy Statement for Canada. Declaration The applicants, proposed insureds and pre-authorized chequing (PAC) payors confirm: they were present when their portion of this application with Sun Life Assurance Company of Canada (company) was completed, they reviewed all of their answers and statements recorded in the application, that all the information they supplied in connection with this application is complete and true, and was provided by them to the advisor (or some other person authorized by the company) for underwriting, administration of insurance and claims paying purposes, they understand that if they do not completely and truthfully answer all of their questions (if they misrepresent any of their answers or statements) the company may void the policy(ies), they agree that their personal, medical and financial information, may be shared as set out in the Sun Life Financial Privacy Statement for Canada, they read and agree to the Acknowledgement of variability, if applicable, they are satisfied with the level of product information they received before signing this application and are aware that additional product information is available to them under the Products and services section of the website at or by calling our toll-free Customer Care Centre at SUN-LIFE ( ), they understand the company is not responsible for the validity of any beneficiary appointments, and PAC payors, by signing below, agree to the terms of the PAC authorization, as set out in section 11. Authorization of all proposed insureds The proposed insureds (parent or legal guardian, if proposed insured is under age 16 (18 in Quebec)) authorize: any health care professional, physician, hospital, clinic or medically-related facility, insurance company, investigation agencies, MIB, Inc. or other organization, institution or person, including the members of the Sun Life Financial group of companies, which includes this company, that have records or knowledge of any proposed insured, to give only that information necessary for underwriting, administration of insurance and claims paying purposes to the company, its representatives and its reinsurers, the performance of such examinations, electrocardiograms, blood profiles, and tests for HIV (AIDS) antibody and hepatitis, if needed to underwrite this application, and the company to release only the necessary personal information obtained during the underwriting process to their personal physician, to MIB, Inc., to the company s reinsurers, to any insurance company, if an application has been made to that company for an insurance policy on their life, and for any infectious or communicable disease, to the Medical Office of Health where required by law. Province signed Date (dd-mm-yyyy) Signature Signed on: Signed on: Signed on: Signed on: Signed on: Signed on: Applicant (indicate title of signing officers if applicable) X Applicant (indicate title of signing officers if applicable) X Proposed insured (if other than applicant or if under age 16 (18 in Quebec) signature of parent or guardian) X Proposed insured (if other than applicant) X PAC payor (if other than applicant or proposed insured) X PAC payor (if other than applicant or proposed insured) X A copy of this authorization is as valid as the original. Sun Life Assurance Company of Canada, Page 17 of 19

18 13 Advisor s report Payment information Payment made with this application $ Future payment frequency m Yearly m Monthly Amount of future periodic payments $ Advisor information Note: Shares must be a minimum of 10%. Is commission being shared? l Yes l No. If yes, provide details. First name of lead service advisor sharing commission Last name Code Share First name of advisor sharing commission Last name Code Share % % Office Office Indicate distribution partner name (MGA, NA or IAP) as well as your own company or advisor address in the box below. Advisor declaration and notice of disclosure (Must be signed by advisor only.) With the understanding that Sun Life will rely on the information to conduct customer due diligence and to satisfy applicable regulatory requirements, I, the advisor, confirm that: all of the identification details provided in this application match the original identification documents shown to me, reasonable effort was exercised to determine if each applicant is acting on behalf of a third party, I have disclosed to each applicant that I am an independent advisor that has a contract to sell products issued by Sun Life Assurance Company of Canada, and I have also identified any other companies I represent, I have disclosed to each applicant that I will receive compensation in the form of commissions or salary for the sale of life and health insurance products, I have disclosed to each applicant that I may also receive additional compensation in the form of bonuses or non-monetary benefits such as travel incentives or attendance at conferences, I have disclosed to each applicant any conflicts of interest that I may have with respect to this transaction, and I am licensed in the province in which this application was completed and this signature page was signed. If applicable (see section 14), I the advisor, also confirm that: I have reviewed with each applicant, proposed insured and PAC payor, all of their information in this application and, to the best of my knowledge, this information is complete and true and has all the facts material to the insurance applied for, and I saw every person sign this application. l I, the advisor, suspect that there is an undisclosed third party involved with this application. Details Advisor s first name Middle initial Last name Office Advisor code address Date (dd-mm-yyyy) Date (dd-mm-yyyy) Advisor s signature X Supervisor s signature X 14 Licensed administrative assistant s declaration (To be completed if a licensed administrative assistant completed the application.) Did a licensed administrative assistant complete the application (excluding section 8)? l Yes l No I, the licensed administrative assistant, confirm that: I have reviewed with each applicant, proposed insured and PAC payor, all of their information in this application and, to the best of my knowledge, this information is complete and true and has all the facts material to the insurance applied for, and I saw every person sign this application. Licensed administrative assistant s first name Middle initial Last name Date (dd-mm-yyyy) Licensed administrative assistant s signature X AGTSTMTE Page 18 of 19 Please submit only one copy of this document. Career Sales Force advisors: Original or fax toll-free to All others: Through your MGA or National Account.

19 Important information you should know Sun Life Financial Privacy Statement for Canada At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives, distribution partners (such as advisors and their companies) and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside of Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. To find out about our Privacy Policy, visit our website at or to obtain information about our privacy practices, send a written request by to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5. Access to your information We or our reinsurers may also submit a brief report of our findings to MIB, Inc. (MIB), a non-profit organization of life and health insurance companies, which operates an information exchange on behalf of its members. If the person named in this application also applies for insurance coverage or submits a claim with another life or health insurance company that is an MIB member, MIB will, on request, supply that insurance company with the information on its files. MIB receives personal information and the collection, use and disclosure of such information is governed by the Personal Information Protection and Electronic Documents Act (PIPEDA) and provincial laws. Therefore, MIB has agreed to protect such information in a manner that is substantially similar to the company s privacy and securities practices, and in accordance with applicable laws. As a U.S. based company, MIB is bound by, and such personal information may be disclosed in accordance with, applicable U.S. laws. If you have any questions about MIB s commitment to protect the confidentiality and security of your personal information, you may contact the MIB Privacy Department at privacy@mib.com. To learn more about MIB, Inc., you may visit the website at call or write to: MIB, Inc. 330 University Avenue Suite 501 Toronto, Ontario M5G 1R7 You may ask to see your personal information on file with MIB, Inc. and correct anything that is inaccurate or incomplete. About Sun Life Financial As a leading international financial services organization, we re proud to offer a diverse range of wealth accumulation and protection products and services. Tracing our roots back to 1865, Sun Life Financial has operations in key markets around the world. But most importantly, we re in business to help people achieve and maintain the peace of mind that comes from having sound financial solutions in place. If you d like more information about Sun Life Financial, please visit our website at or call SUN-LIFE ( ). ADMIN1E Page 19 of 19 Please detach and give this sheet to the proposed insured.