Application for life and/or critical illness insurance

Transcription

1 Application for life and/or critical illness insurance Contents Instructions for the advisor (tear away page) Section 1 General information... 1 Section 2 Information about the people to be insured... 2 Section 3 Policy ship... 3 Section 4 Beneficiary information... 5 Section 5 Conversions/replacements/options exercised... 7 Section 6 Plan/benefit information... 8 Section 7 Acknowledgement of variability Section 8 Identity verification/third party determination/politically exposed foreign person (PEFP)/source of payment Section 9 Personal information Section 10 Medical advisor/clinic information Section 11 Family history Section 12 Height and weight Section 13 Personal medical history Section 14 Child(ren) to be insured under a child term benefit (CTB) Section 15 Authorization to disclose information to your advisor Section 16 Temporary insurance/payments/policy statements Section 17 Acknowledgement and agreement Section 18 Advisor s report Important information you should know (tear away page) Certificate of temporary insurance (tear away page) Information page only do not submit with application

2 Instructions for the advisor Application use: Use this application to apply for: all life insurance products for up to two proposed insureds and five children under the child term benefit (CTB) all critical illness insurance products with one proposed insured all replacements all conversions with an increase in coverage (excluding the addition of a Child term benefit), and all options exercised with an increase in coverage. Notes: If there are more people to be insured under the same policy, complete a second application form and complete section 1.2 of this application. If a tele-interview or paramedical will be completed, use the combined RapidApp/Tele-interviewing application for life and/or critical illness insurance ( ) instead of this application. For all conversions/options exercised with no increase in coverage or if adding a Child term benefit, use the Application for conversion and exercising an option (E260) instead of this application. For changes to the smoking status of your policy, with an increase in coverage that requires underwriting, complete an Application for policy change, reinstatement and/or reconsideration of rating (E110) instead of this application. For changes to the smoking status of your policy only (no other changes to be made), complete the Declaration of smoking status form (E18) instead of this application. For all long term care insurance applications, complete the Application for long term care insurance ( ). Important: If a child is to be one of the primary insureds, provide the information for that child in the Person 1 or boxes. All cheques must be in Canadian funds, drawn from a Canadian financial institution and payable to Sun Life Assurance Company of Canada. Ensure you have arranged for all applicable age and amount evidence requirements. Tear off the Important information you should know page and give it to the proposed insured. Tear off the Certificate of temporary insurance page and give it to the proposed, if applied for. Indicate clearly with an X when selecting check boxes. A signed illustration must be completed for all Sun Par Protector, Sun Par Accumulator, SunUniversalLife, SunUniversalLife Max and Sun Limited Pay Life applications. All pages of the application must be submitted with the exception of the tear away pages. Ensure you have attached the following to the application: if temporary insurance has been applied for, a cheque or authorization to withdraw the initial payment the signed illustration for all Sun Par Protector, Sun Par Accumulator, SunUniversalLife, SunUniversalLife Max and Sun Limited Pay Life applications, and for replacements, the appropriate replacement form(s), completed and signed. Please submit only one copy of this document to Sun Life through your MGA or National Account.

3 Application for life and/or critical illness insurance Policy no. (For H.O. use only.) Please PRINT clearly In this application, I, you, your, Person 1 and refer to the proposed insured(s) and/or the proposed (s). We, us, our and the company refer to Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. At the start of each section, we ve stated who I, you and your refer to in that section. 1 General information In this section, you and your refer to the proposed (s). 1.1 What are you applying for? Tell us what type of insurance you re applying for and complete the required illustration. Also, tell us if you re insuring any children under a child term benefit. Select all that apply: m Life insurance number of people being insured under this policy number m New business or m Conversion/option exercised with an increase in coverage or replacement m Single life or m Joint or m Multi-life m Critical illness insurance (CII) m Child term benefit (CTB) 1.2 Are you applying for additional or optional coverage? m Yes m No If yes, indicate the type of coverage you re applying for: m Additional m Optional If yes, indicate amount: 1.3 What is the purpose of this insurance? Select all that apply: m Income replacement m Tax or estate planning m Buy-sell agreement m Creditor protection m Key person insurance m Concept/other (give details in the box below) If coverage is for business-related needs, complete the following: First name(s) of business (s) Last name(s) % of business owned Total amount of business insurance already in force with all companies Total amount of new business insurance to be put into effect with all companies Annual sales Net after tax income % % % % Fair market value AAPPE Page 1 of 39 Please submit only one copy of this document to Sun Life through your MGA or National Account.

4 1 General information (continued) 1.4 Have you completed another application to insure other people under this application? m Yes m No If yes, indicate name and date of birth. First name(s) Middle initial Last name(s) Date(s) of birth (dd-mm-yyyy) 1.5 What language would you like your policy to be in? m Issue the policy in English m Établir le contrat en français 2 Information about the people to be insured In this section, you, your, Person 1 and refer to the proposed insured(s). If any proposed insured is a minor, the minor s parent or legal guardian must provide the information on their behalf. 2.1 Person 1 Note: Only provide Person 1 s Social Insurance Number (SIN) if they are also the proposed. First name Middle initial Last name m Male m Female Former last name (if any) Country of birth City of birth 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; do not provide if applying for CII only) Home phone number Cell phone number Driver s licence number What is your residency status? m Canadian citizen m Permanent resident status (landed immigrant) m Other Province Business phone number Ext. If Permanent resident or Other, provide details including number of years in Canada. If you are also a proposed 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 If yes, provide a U.S Taxpayer Identification Number (TIN). Does the proposed want to retain age? m Yes m No Note: Age may be retained up to 90 days. Page 2 of 39

5 2 Information about the people to be insured (continued) 2.2 Note: Only provide s Social Insurance Number (SIN) if they are also the proposed. m Address is same as Person 1 above. If you ve ticked this box, you may leave the address boxes blank. First name Middle initial Last name m Male m Female Former last name (if any) Country of birth City of birth 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; do not provide if applying for CII only) Home phone number Cell phone number Driver s licence number What is your residency status? m Canadian citizen m Permanent resident status (landed immigrant) m Other Province Business phone number Ext. If Permanent resident or Other, provide details including number of years in Canada. If you are also a proposed 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 If yes, provide a U.S Taxpayer Identification Number (TIN). Does the proposed want to retain age? m Yes m No Note: Age may be retained up to 90 days. 3 Policy ship In this section, you and your refer to the proposed (s). 3.1 (s) Who will own this policy? (Select all that apply.) m Person 1 to be insured m to be insured m Individual(s) other than Person 1 or 2 m Corporation or Trust Note: For Person 1 and 2, proceed to section 3.2 on next page as the required information will be taken from section 2. For all others, complete the following applicable sections. 1 First name Middle initial Last name m Male m 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; do not provide if applying for CII only) 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). Page 3 of 39

6 3 Policy ship (continued) 2 m Address is same as 1. If you ve ticked this box, you may leave the address boxes blank. First name Middle initial Last name m Male m 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; do not provide if applying for CII only) 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). Corporation, trust or other entity Note: For all non-individual s, additional forms may be required as described in section 8. Name Title of person to whom all notices, statements and correspondence about this policy are to be sent Mailing address (street number and name) Apartment or suite City Province Country Postal code 3.2 Additional information The following question must be completed if: any proposed insured is age 65 or greater, and the application is for a universal or permanent life plan (including special issues), and the death benefit amount applied for is greater than 1,000,000. Is this policy being purchased with the intent of transferring ship in the policy? m Yes m No If yes, provide full details in the box below. 3.3 Mailing information Indicate the proposed s address selection for all notifications and policy statements: (Choose one.) m Address of Person 1 to be insured m Address of to be insured m Address of 1 m Address of 2, or m Other If other, provide address below. Residential address (street number and name) Apartment or suite City Province Postal code Page 4 of 39

7 3 Policy ship (continued) 3.4 contingent (s) Notes: If one proposed and the policy will continue after that s death (where the proposed is not the proposed insured person). If more than one proposed with multiple s outside of Quebec If this policy is owned by more than one person and an dies, their interest will pass in equal shares to the surviving s unless a contingent is named for them. If, on the death of any, that deceased s interest is to pass to a named contingent, then the name of the contingent must be completed in the space provided below next to the applicable s name. If more than one proposed with multiple s in Quebec Survivorship provisions do not apply in Quebec. If one of the s die, their interest in the policy will pass to the contingent named below. The surviving will continue to own their interest in the policy. Indicate the name of the proposed and their contingent in the space provided below. Owner 1 Owner 2 Owner 3 Owner 4 Owner 5 Contingent Relationship to the proposed 4 Beneficiary information In this section, you and your refer to the proposed (s). Notes: 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 SunLimitedPayLife with minimum guaranteed death benefit of 250,000. 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 any beneficiary designation section. 4.1 Life insurance designations a) Primary beneficiaries (Share of benefits must add up to 100%.) Notes: If not completed, any beneficiary will be the proposed or the estate of the proposed. 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. Page 5 of 39

8 4 Beneficiary information (continued) First name (for Person 1) Middle initial Last name Relationship to proposed insured (In Quebec, relationship to proposed ) Beneficiary designation m Revocable m Irrevocable m Revocable m Irrevocable % share of benefits to be paid m Revocable m Irrevocable Total 100% (for ) m Revocable m Irrevocable m Revocable m Irrevocable m Revocable m Irrevocable Total 100% b) Contingent beneficiaries (Share of benefits must add up to 100%.) First name (for Person 1) (for ) Middle initial Last name Relationship to proposed insured (In Quebec, relationship to proposed ) Beneficiary designation m Revocable m Irrevocable m Revocable m Irrevocable % share of benefits to be paid 4.2 Critical illness insurance designations Note: If you designate a payee, you will not receive the critical illness benefit payment. a) Benefit payee beneficiary Note: If not completed, the beneficiary is the proposed or the estate of the proposed. First name Middle initial Last name Relationship to proposed insured (In Quebec, relationship to proposed ) Beneficiary designation m Revocable m Irrevocable b) Return of premium on death benefit beneficiary Notes: If not completed, the beneficiary will be the proposed or the estate of the proposed. We pay any Return of premium on cancellation or expiry benefits to the proposed or the estate of the proposed. First name Middle initial Last name Relationship to proposed insured (In Quebec, relationship to proposed ) Beneficiary designation m Revocable m Irrevocable 4.3 Trustee for minor beneficiary designations for life and critical illness Notes: Complete when a minor beneficiary has been named in beneficiary designation sections 4.1 or 4.2. 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. a) Primary beneficiaries: I appoint b) Contingent beneficiaries: I appoint Page 6 of 39

9 4 Beneficiary information (continued) c) Benefit payee beneficiary: I appoint d) Return of premium on death benefit beneficiary: 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. 5 Conversions/replacements/options exercised Complete this section for all conversions/options exercised with an increase in coverage and replacements. Notes: For replacements, a Comparison Disclosure Statement or Life Insurance Replacement Declaration is required by regulation for a life insurance application that will replace an existing life insurance policy or application (not required for critical illness insurance except in Quebec). For partial replacements, when terminating the rest of the existing policy number being replaced, a Comparison Disclosure Statement or Life Insurance Replacement Declaration is required by regulation. If more than one policy is being replaced, a separate Comparison Disclosure Statement or Life Insurance Replacement Declaration is required for each policy that is being replaced. The policies listed below will be terminated or amended on the date that any insurance applied for in this application becomes effective. Termination or amendment of the policies listed below may result in the loss of one or more benefits such as: Waiver of premium/disability, Accidental death, policy loans at 6% interest, Guaranteed insurability, Disability income, Critical illness insurance, insurance coverage on other lives or beneficial tax treatments. This transaction may result in a taxable policy gain. Any change may be subject to restrictions on the amount of premium and death benefit, as determined by the company at the time of the change. The company may require evidence of insurability. All credits from the terminated policies will be transferred to the policy being applied for. On SunUniversalLife, SunUniversalLife Max or Sun Limited Pay Life policies, any net credit remaining from any money paid with this application will be invested from the date received in the Investment account options selected, subject to applicable minimums. If only applying for a change to the smoking status of your policy, with an increase in coverage that requires underwriting, complete an Application for policy change, reinstatement and/or reconsideration of rating (E110) instead of this application. 5.1 Disability status Note: This question must be answered by the proposed insured. If the proposed insured is under age 16 (18 in Quebec), the question must be answered by the parent or legal guardian. Is the proposed insured currently disabled or claiming on the disability benefit of any of their policies? m Yes m No If yes, indicate policy no.: (, ) 5.2 Conversions, replacements and options exercised information a) Provide the policy number of any insurance policies with the company to be fully terminated by this application (e.g., replacements, full conversion or partial conversion with balance terminated or attached to the new plan). b) Provide the policy number of any insurance policies with the company on which the death benefit is being reduced (e.g., partial conversion or conversion of attached plan with balance being retained in the existing policy). c) Provide the policy number of any insurance policies with the company on which a Guaranteed insurability option, or options on Child term, Spousal term, Attached term on the insured spouse, Attached term on the additional insured person, Business value protection or Partner protection is being exercised. Page 7 of 39

10 5 Conversions/replacements/options exercised (continued) d) Additional instructions 6 Plan/benefit information In this section: you and your refer to the proposed (s), and Person 1 and refer to proposed insured person 1 and proposed insured person 2 unless otherwise indicated. 6.1 SunTerm m 10 year m 15 year m 20 year m 30 year a) m Single life m Joint first-to-die m Multi-life m 10 year m 15 year (Complete for.) m 20 year m 30 year b) Risk classification applied for on Person 1 m 1 non-smoker m 2 non-smoker m 3 non-smoker m 4 smoker m 5 smoker c) Risk classification applied for on m 1 non-smoker m 2 non-smoker m 3 non-smoker m 4 smoker m 5 smoker 6.2 Sun Par Protector or Sun Par Accumulator m 20 pay m Life pay (to age 100) m 20 pay m Life pay (to age 100) m Pay to age 65 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 (Choose one.) m Paid-up additional insurance (PUA) 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) Page 8 of 39

11 6 Plan/benefit information (continued) c) 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. d) 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 meeting 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. 6.3 SunUniversalLife or SunUniversalLife Max a) m Single life m Joint first-to-die m Joint last-to-die m Multi-life (Complete for.) b) Death benefit options (Choose one.) m Level insurance amount m Indexed insurance amount (Check one.) m at % per year (specify between 1% and 8%, in multiples of 0.25%) m at the annual rate of Canada s Consumer Price Index (to a maximum of 8% per year) m Insurance amount plus your policy fund value For multi-life coverage, the policy fund value will be paid as a proportion of each insurance amount to the total, unless you tell us your policy fund value is to be paid with the m first or m last settlement of basic insurance benefit under the policy. m Fund builder Fund builder is a variation of the Insurance amount plus fund option. 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 c) Investment bonus m Yes m No d) Cost of insurance m Person 1 m m Guaranteed yearly term m Guaranteed yearly term m Guaranteed level m Guaranteed level e) Investment account options You must allocate your payment 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 We ll move your payment to your Investment account options when the amount you give us is large enough to put at least in each of your selected options. Page 9 of 39

12 6 Plan/benefit information (continued) If you ve selected an Investment account option which is no longer available but is not yet 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. We will move your funds from the Daily interest account (DIA) to your alternative selection on the date you tell us. 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 American Equity American Technology Canadian Bond Canadian Equity European Equity Foreign Equity FPX Balanced FPX Growth FPX Income Japanese Equity Pacific Equity Percentage 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 Percentage 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: m 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 m Alternative order: or m Proportional order: Activity account Activity account Activity account Daily interest account Daily interest account Proportional across all options Accounts based on the GIAs (nearest to maturity) performance of indices Accounts based on the Accounts based on the performance of indices performance of managed funds Accounts based on performance GIAs (nearest to maturity) of managed funds Page 10 of 39

13 6 Plan/benefit information (continued) f) Maintaining your policy s tax-exempt status Note: Do not check a box if you ve chosen Fund builder death benefit. Check one of the boxes below: m Retain insurance amount m 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) m 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.) m Refund them to the policy m 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 g) Defaults If the required illustration isn t attached with this application and/or you haven t provided all the required information, your policy will have the following options: Death benefit option Insurance amount plus your policy fund value Investment bonus no Cost of insurance Guaranteed level rates Excess funds Transfer to daily interest account Tax-exempt status 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) Investment account options Daily interest account 100% Withdrawal order Proportional per account balance 6.4 Sun Limited Pay Life m 10 year m 15 year m 20 year m Pay to age 65 (Available on single life only.) a) m Single life m Joint last-to-die b) Investment account options You must allocate your payment 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 We ll move your payment to your Investment account options when the amount you give us is large enough to put at least in each of your selected options. 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 NorthStar Fidelity True North Mackenzie Cundill Value Mackenzie Ivy Foreign Equity Sun Life MFS US Equity Percentage Sub total % + Sub total % + Sub total % = 100% Page 11 of 39

14 6 Plan/benefit information (continued) 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: m 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 m Alternative order: or m Proportional order: Daily interest account Daily interest account Activity account Accounts based on the GIAs (nearest to maturity) Proportional per account balance performance of indices Accounts based on the in this order: performance of indices FPX Income, FPX Balanced, in this order: FPX Growth, Canadian Equity, FPX Income, FPX Balanced, American Equity, Canadian Bond FPX Growth, Canadian Equity, Accounts based on the American Equity, Canadian Bond performance of managed funds Accounts based on the in proportion to the balance of performance of managed funds each of those accounts in proportion to the balance of GIAs (nearest to maturity) each of those accounts Long Term Managed Portfolio Long Term Managed Portfolio c) 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. m Refund them to the policy m 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 d) Defaults If the required illustration isn t attached with this application and/or you haven t provided all the required information, your policy will have the following options: Excess funds Transfer to daily interest account Investment account options Daily interest account 100% Withdrawal order Proportional per account balance 6.5 Sun Critical Illness Insurance m Term 10 m Term 75 Guaranteed payment period m 15 years m To age 75 m Lifetime Guaranteed payment period m 10 years m 15 years m To age 100 If you are applying for a conversion and if the previous critical illness policy did not have all illnesses that are available on the base plan you have applied for, do you want to apply for these illnesses and submit evidence? m Yes m No 6.6 Other Name of plan Page 12 of 39

15 6 Plan/benefit information (continued) 6.7 Optional benefits Note: Not all additional benefits are available with every type of insurance plan. Advisors should refer to our illustration software for availability. a) Available on life plans m Total disability waiver m Person 1 m m Accidental death Person 1 m Guaranteed insurability Person 1 m Child term Person 1 m Owner waiver disability Note: Complete sections 9-13 on the proposed. m Business value protection Person 1 m Renewal protection (SunTerm 10 only) m Person 1 m m Partner protection (SunTerm only with 3 or more proposed insureds.) m Other benefits m Person 1 m Benefit name Benefit name b) Sun Par Protector and Sun Par Accumulator only 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) m Term insurance benefit on Person 1 m 5 year m 10 year m 20 year m Term insurance benefit on m 5 year m 10 year m 20 year m Owner waiver on disability benefit Note: Complete sections 9-13 on the proposed. m Owner waiver on death benefit Note: Complete sections 9-13 on the proposed. Page 13 of 39

16 6 Plan/benefit information (continued) c) SunUniversalLife and SunUniversalLife Max only m Total disability benefit on Person 1 (Check one box only.) m Protection To age or m Savings To age Specify amount m Total disability benefit on (Check one box only.) m Protection To age or m Savings To age Specify amount m Owner disability benefit (Check one box only.) m Protection To age or m Savings To age Specify amount Note: Complete sections 9-13 on the proposed. m Owner death benefit (Check one box only.) m Protection To age or m Savings To age Specify amount Note: Complete sections 9-13 on the proposed. m Term insurance benefit on Person 1 m Term insurance benefit on m 5 year m 10 year m 20 year m 5 year m 10 year m 20 year m Executive guaranteed insurability benefit First amount In year Fourth amount In year Second amount In year Fifth amount In year Third amount In year m Coverage death benefit (Check one box only.) m Protection To age or m Savings To age Specify amount d) Sun Critical Illness Insurance only Note: An increase or addition to the Sun Critical Illness attached benefits is not available after the policy is issued, with the exception of the Long term care conversion option. This option may only be added after the policy is issued on juvenile policies between the policy anniversaries nearest the insured person s 18 th and 19 th birthday. m Disability waiver benefit m Loss of independent existence (additional Group 1 illness) m Long term care conversion option m Return of premium on: m Death benefit m Cancellation or expiry benefit (Term 10 or Term 75) m Adult: m 15 years m age 65 m age 65 m Child m Child m Cancellation benefit (Lifetime only) m Adult: m 15 years Page 14 of 39

17 7 Acknowledgement of variability In this section, I refers to the proposed (s). 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 payments 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 15 of 39

18 8 Identity verification, third party determination and politically exposed foreign person (PEFP) Notes: In this section, you and your refer to the proposed (s). The questions must be answered by the proposed s(s) of the application. Completion is mandatory for all universal and permanent life applications. If any proposed is not an individual (ie. Corporation or other entity), the following must be completed for that proposed : 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 proposed. If you have completed form 4104, indicate how many have been completed for this application: 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 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 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 proposed / 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 16 of 39

19 8 Identity verification, third party determination and politically exposed foreign person (PEFP) (continued) First name Middle initial Last name Date of birth (dd-mm-yyyy) Relationship to proposed / 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 If unable to obtain any required information for any third party, give details as to why below. 8.2 To the best of the proposed s knowledge, has the proposed 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 9. military officer with a rank of general or above 2. head of government 10. president (head) of state-owned company 3. member of the executive council of government 11. president (head) of a state-owned bank 4. member of legislature 12. head of a government agency 5. deputy minister (or equivalent rank) in government 13. judge of a supreme court, constitutional court or 6. ambassador other court of last resort 7. counsellor of an ambassador 14. leader (or president) of a political party 8. attaché 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, biological/adoptive/step-parent of the proposed, biological/ adoptive/step-parent of spouse, civil union spouse or common-law partner. s first name Middle initial Last name First name (PEFP) 1 Middle initial Last name Relationship to proposed 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 proposed 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 the box below) m other (give details in the box below) 8.4 What is the purpose and intended use of the product applied for? income replacement mortgage protection creditor protection asset protection estate protection business protection charitable donation tax or estate planning other (give details below) Page 17 of 39

20 Person 1 9 Personal information In this section, you and your refer to the proposed insured(s) and/or proposed. The questions must be answered by the proposed insured(s) and/or the proposed of the policy who has applied for an waiver, disability or death benefit. If a proposed insured is under age 16 (18 in Quebec), the questions must be answered by the parent or legal guardian. Note: Only provide information for the proposed in sections 9-13 if you ve applied for additional Owner waiver, disability or death benefits. 9.1 Smoking and tobacco use Notes: Question in 9.1 does not need to be answered for proposed insureds under the age of 16. Question in 9.1 does not need to be answered on conversion applications where smoker/non-smoker rates are being carried over to the new policy. Person 1 In the last 5 years, have you 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? If yes, provide details.... m Yes m No m Yes m No m Yes m No insured Product(s) Amount(s) and frequency of use Date(s) last used (dd-mm-yyyy) Person Insurance history and replacement/disclosure statements and/or Life Insurance Replacement Declarations Person 1 a) Do you have any existing life and/or critical illness insurance in force on your life?.. m Yes m No m Yes m No m Yes m No If yes, complete the following. insured Person 1 Date(s) issued (mm-yyyy) Plan type(s) m Life m CII Amount(s) (including benefits) Company name(s) Replacing m Yes m No Business or personal m Business m Personal m Life m CII m Yes m No m Business m Personal m Life m CII m Yes m No m Business m Personal EAPPE Page 18 of 39 Policy no. (for H.O. use only)