Sun Life Financial / Financière Sun Life

Member and dependent details

This section is to be completed by the plan member.

All information received by Sun Life Assurance Company of Canada is treated as strictly confidential and is used for the sole purpose of determining your eligibility and administering the group plan to which you belong.

Information marked with * is required.

2.1 General information about the member

First name:

Middle initial:

Last name:

Date of birth:

Gender:

Male Female

Height:

ft/in m/cm

ft in

Weight:

lb kg

Contract number:

Address 1:

Address 2: (include apt/suite#)

City or town:

Country:

Province or state:

Postal code or zip code:

(L#L #L#)

Preferred method of contact:

Select all that apply

Phone E-mail Fax

E-mail address:

Please provide all applicable contact information where you can be reached for any questions about this application

Home Business Cell Fax

Home telephone
Area code:	(xxx)
Telephone number:	(xxx-xxxx)

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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.