SUN LIFE ASSURANCE COMPANY OF CANADA (U.S.)
WELLESLEY HILLS, MA 02481
Company/Owner Name ____________________________________________________________
PROPOSED INSURED CONSENT FORM
I agree to the purchase of life insurance on my life by the Owner listed
above and in accordance with the Master Application for Corporate Life
Insurance which is incorporated as part of this consent. I understand that
the Owner will be the Owner and Beneficiary of the certificate insuring my
life. I understand that any benefits from such life insurance are payable to
the Owner, and that I have no ownership or beneficial interest or
rights in the life insurance.
1. Proposed Insured's Name ________________________ 2. Male / / Female / /
3. Date of Birth ___-___-___ 4. Age ___ 5. Social Security Number ___-___-___
6. Specified Face Amount ____________________________
7. Additional Protection Benefit Rider Face Amount __________________________
QUESTIONS
8. During the past 3 months, have you been actively at
work on a full-time basis, at least 30 hours per week
in a normal capacity, and not been absent for more than
five consecutive days due to illness or medical treatment? YES / / NO / /
IF NO, GIVE DETAILS:
______________________________________________________________________________
______________________________________________________________________________
9. Have you used tobacco (cigarettes, cigars, chewing YES / / NO / /
tobacco, pipe, etc.) or any other substance containing
nicotine, including Nicorette gum, within the past
twelve months?
IF YES, PLEASE LIST TYPE AND NUMBER OF EACH PRODUCT USED PER DAY:
_______________________________________________________________________________
AGREEMENT and AUTHORIZATION
I agree that all statements and answers in this consent form are true and
complete to the best of my knowledge and belief. This consent form shall be
attached to and form a part of any certificate of insurance issued. As long
as I continue to work for the Owner, the Insurer can change the amount of
insurance in accordance with the Owner's written request to change such
amount. Each change shall be subject to the Insurer's underwriting
limitations and requirements then in effect, including but not limited to my
being actively at work at the time of the change. I authorize the Owner
listed above to release any information it has on me or my health to the
Insurer. This information may be used to determine eligibility for
insurance. This authorization is valid for thirty (30) months from its date.
A photocopy of this authorization shall be as valid as the original.
Signature of Proposed Insured _____________________________ Date _______________
Signature of Witness/Sales Representative __________________License No. ________
COLI 2001 -CONSENT
