Sun Life Financial / Financière Sun Life

Administration information

This section is to be completed by the Plan Administrator, or the member with information provided by the Plan Administrator.

Coverage is not in effect until you receive notice of approval from Sun Life Assurance Company of Canada.

Information marked with an * is required.

Member information

Title:	*
First name:	*
Middle initial:
Last name:	*
Important: Please check the member's date of birth to ensure it is correct. This date is used to authenticate the member's identity when signing in to the electronic Health Statement.
Date of birth:	*	day month year
Contract number:	*
Member ID:	*
Billing group:	*
Class:	*
Occupation:	*
Salary frequency:	*
Salary:	*	(x,xxx.xx)

Plan administrator information

Plan administrator's first name:	*
Plan administrator's last name:	*
Company name:	*
Address 1:	*
Address 2: (include apt/suite#)
City or town:	*
Country:	*
Province/State:	*
Province/State:	*
Province/State:
Postal code or zip code:	* (L#L #L#)
Area code:	* (xxx)
Telephone number:	* (xxx-xxxx)
Telephone extension:	(xxxxx)


Reason for electronic Health Statement:	*
	* Effective date: day month year

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Any changes you make on this site may affect information about your particular plan,
offered by Sun Life Assurance Company of Canada.