Insurer Address: One Sun Life Executive Park, Wellesley Hills, MA 02481
Sun
Life Insurance and Annuity Company of New York
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Insurer
Address: Xxx
Xxx Xxxx Xxxxxxxxx Xxxx, Xxxxxxxxx Xxxxx, XX
00000
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Company/Owner Name
______________________________________________________________________________
The
Company/Owner listed above (the “Owner”) 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
understand that the Owner listed above has decided to implement a corporate
owned life insurance program (“Program”) which purchases life insurance coverage
(“coverage”) on the lives of its employees to offset and/or recapture the cost
of providing employee benefits.
Under
this Program, I understand that:
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(a)
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I
must be informed in writing that coverage is being obtained, prior to the
commencement of coverage on my life. Furthermore, at the time
my employment terminates, I must be notified of my right to discontinue
such coverage. I understand that such notification is not
required if I possess a present or prospective right to receive any of the
benefits under an employee benefit plan being financed, in whole or in
part, by such life insurance
coverage;
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(b)
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I
must provide consent in writing to the
coverage.
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(c) I
have the right to withdraw my consent and to discontinue the coverage at
any time by providing written notification to the
Company.
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r I consent to
the purchase of life insurance on my life by the Owner. I understand
that the Owner will be the owner and beneficiary
of
the policy. 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.
r I do not consent to the
purchase of life insurance on my life
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
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6.
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During
the past 3 months, has the Proposed Insured, been actively at work on
a full-time basis,
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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:
_____________________________________________________________________________
______________________________________________________________________________
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7.
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Has
the proposed Insured used tobacco (cigarettes, cigars, chewing tobacco,
pipe, etc.) or any other substance
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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, has 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 Acquired Immune Deficiency Syndrome
(AIDS)? YES r NO r
If yes, give
details:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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 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.] 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.
Signature
of Proposed
Insured ___________________________________________
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Authorization
for Release and Disclosure of Underwriting
Information
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I hereby
authorize any: (a) physician, health care provider, medical professional,
hospital, clinic, or other medical or health care related facility or service;
(b) insurance company; (c) state department of motor vehicles; (d) consumer
reporting agency; or (e) the Medical Information Bureau, Inc., to disclose or
furnish to the Underwriting Department of Sun Life Insurance and Annuity Company
of New York (together, the “Insurer”) their subsidiaries, affiliates, third
party administrators, and reinsurers, any and all information relating to me. I
understand that such information may include records relating to my physical or
mental condition such as diagnostic tests, physical examination notes and
treatment histories.
Upon
written request, the MIB will arrange disclosure of any information it may have
about you in its files. If you question the accuracy of information
in your file you may contact the Medical Information Bureau, Inc. at P.O. Box
105, Essex Station, Boston, Massachusetts 02112 (telephone
000-000-0000). You may seek to have MIB correct information in your
file pursuant to the Federal Fair Credit Reporting Act.
I
understand that the Insurer will use the information it obtains to determine if
I am eligible for life insurance coverage with the Insurer and to determine the
premium to be paid for such coverage.
I
hereby authorize the Insurer to disclose any information it obtains about me to
the Medical Information Bureau, Inc. or any other life insurance company with
which I do business. I understand that the Insurer will not disclose
information it obtains about me except as authorized by this Authorization, as
may be required or permitted by law or as I may further authorize. I
understand that if information is re-disclosed as permitted by this
Authorization, it may no longer be protected by applicable federal privacy
law.
I
understand that: (a) this Authorization shall be valid for twenty-four (24)
months from the date I sign it; (b) I may revoke it at any time by providing
written notice to Underwriting Department of the Insurer, subject to the rights
of any person who acted in reliance on it prior to receiving notice of its
revocation; and (c) my authorized representative and I are entitled to receive a
copy of the Authorization upon request. The address of the Insurer is
provided on page one (1).
A copy of
this Authorization shall be as valid as the original.
Signed
At _______________________________________ ___________________________________________________
Signature of Proposed
Insured
Date ______________________________
2008
45/13 – Consent NY XGI
EBP Page of
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