Group Benefits Enrolment Form
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Complete Group Benefits Enrolment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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3Group benefits enrolment form
Keeping your information confidential
Clear
Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies, is committed to keeping your information
confidential. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third-party providers
and reinsurers who, in some instances, may be located in jurisdictions outside Canada. Your personal information may be subject to the
laws of those foreign jurisdictions. Sun Life Financial’s operations worldwide and our third-party providers are required to protect the
confidentiality of your personal information in a manner that is consistent with our privacy policy and practices.
To find out about our Privacy Policy, visit our website at , or to obtain information about our privacy practices, send a written
request by email to , or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.
You have a choice
We will occasionally inform you of other financial products and services that we believe meet your changing needs. If you do not wish to
receive these offers, let us know by calling 1-877-SUN-LIFE (1-877-786-5433).
Instructions
• Section 1 is to be completed by the plan administrator.
• All remaining sections are to be completed by the plan member and returned to your plan administrator.
Please PRINT clearly. Complete the form in ink, sign and date the form on page 3 and return to your plan administrator for handling.
I
1
Information to be completed by plan administrator
Contract number
Class/Plan
Plan member ID
Date of hire/re-hire (yyyy-mm-dd)
New plan member
–
–
Re-hire
Location/billing group number
Location/billing group name
Contract holder name
Effective date of coverage (yyyy-mm-dd)
Occupation
Salary
Basis
Annual
Semi-monthly
Other
_________________
(please specify)
–
–
Monthly
Weekly
$
Bi-weekly
Hourly (Hrs./Wk.
___________
)
I
2
Plan member details
Plan member’s last name
Middle initial
First name
Gender
Male
Language
English
Female
French
Address (street number and name)
Apartment or suite
City
Province
Postal code
Date of birth (yyyy-mm-dd)
Email address
–
–
Province of residence
Province of employment
Marital status
Single
Married
Common Law
Civil Union
Coverage selection
Single
Divorced
Separated
Widowed
Family
I
3
Refusal of benefits
If you or your dependents are presently covered for Extended Health Care and/or Dental Care benefits under another group contract you
may refuse to be covered for such benefit(s) under this contract by selecting the applicable box for each benefit:
I refuse coverage for myself and my dependents under:
Extended Health Care
Dental Care
Extended Health Care
Dental Care
I refuse coverage for my dependents under:
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