Sun Life Assurance Company of Canada (U.S) Sun Life Assurance Company of Canada
Sun
Life Assurance Company of Canada (U.S)
Sun
Life Assurance Company of Canada
One
Sun Life Executive Park, Wellesley Hills, MA 02481
Company/Owner
Name
______________________________________________________________________________
The
Company/Owner listed above (the åOwneræ) intends to purchase a life insurance
policy or policies on the life of the Proposed Insured listed below.
In
advance of any policy issuance [or material increase], the Proposed Insured
will
be notified in writing of the maximum total amount of insurance to be purchased
at the time the policy or policies are issued.
I
hereby
consent to the purchase of life insurance on my life by the Company/Owner (the
åOwneræ) listed above and in accordance with the Master Application for
Corporate Life Insurance which is incorporated as part of this consent. I
acknowledge that the policy or policies so purchased may remain in force after
my termination of employment from the Owner. I
understand that the Owner will be the owner and beneficiary of the policy or
policies, and that any benefits from such life insurance are payable to the
Owner. Neither I, my heirs, assignees, estate, nor administrators have any
ownership or beneficial interest or rights in the policy or policies or in
any
policy proceeds, unless the Owner otherwise notifies the insurer.
The
maximum amount of insurance that will be purchased on my life at the time the
policy or policies are issued is $______________.
Proposed
Insured Information
1.
Proposed Insured’s Name ________________________________________________________
2. Male r
Female
r
3.
Date
of Birth ______ - ______ - _____
4. Age
______ 5.
Social
Security Number ______ - ______ - ______
QUESTIONS
6.
During
the past 3 months, have you, the Proposed Insured, 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
r
NO
r
If
no, give details:
_____________________________________________________________________________
______________________________________________________________________________
7.
Have
you, the Proposed Insured, used tobacco (cigarettes, cigars, chewing 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: YES
r NO
r
_______________________________________________________________________________
8.
In the
past 10 years, have you, the Proposed Insured, been treated for:
Any
disorder of the heart or blood vessels, tumor or cancer, diabetes, stroke,
or
any disorder of the
blood,
lungs, kidneys, drug or alcohol use, depression or been diagnosed or treated
by
a doctor or
other
medical practitioner for Human Immunodeficiency Virus or Acquired Immune
Deficiency
Syndrome
(AIDS)? YES
r NO
r
If
yes, give details:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
AGREEMENT
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 policy 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].
Signature
of Proposed Insured: _________________________________________________________
Date: ___________________
Sun
Life
Assurance Company of Canada and Sun Life Assurance Company of Canada and (U.S.)
are both members of the Sun Life
Financial
group of companies.
