Group benefits enrolment form

Enrollment Form

Keeping your information confidential
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 www.sunlife.ca, or to obtain information about our privacy practices, send a written request by email to [email protected], 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.

1 Information to be completed by plan administrator

title(Required)
Date of hire/re-hire (yyyy-mm-dd)
Effective date of coverage (yyyy-mm-dd
Basis
Untitled

2 Plan member details

Gender(Required)
Language(Required)
Date of birth (yyyy-mm-dd)(Required)
Marital status(Required)
Coverage selection(Required)

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:
I refuse coverage for myself and my dependents under:
I refuse coverage for my dependents under:
I refuse coverage for my dependents under:

4 Banking details

If you wish to have your Extended Health Care and/or Dental Care benefit payments deposited directly into your bank account, attach a void cheque, direct deposit form or bank verification statement.

If you do not have a chequing account, you must provide a direct deposit form or bank verification statement from your bank branch. This form must be provided by your bank, trust company, caisse populaire or credit union in Canada, and be signed and stamped by a banking representative. If your bank provides an online direct deposit form, pre-populated with your banking information, this can also be submitted. These forms must contain your name, the Bank Number, your Branch Number and Account Number to facilitate your benefit payment being deposited directly into your account.
Max. file size: 100 MB.

5 Spouse details – complete this section only if you are applying for coverage for your spouse

Gender
Date of birth (yyyy-mm-dd)
Is your spouse covered for Extended Health Care and/or Dental Care benefits by his/her employer’s plan?
If yes, please indicate spouse’s coverage:
Extended Health Care
Dental Care

6 Children details – complete this section only if you are applying for coverage for your children

Date of birth (yyyy-mm-dd)
Gender
Student*
Over-age disabled child**
Date of birth (yyyy-mm-dd)
Gender
Student*
Over-age disabled child**
Date of birth (yyyy-mm-dd)
Gender
Student*
Over-age disabled child**
Date of birth (yyyy-mm-dd)
Gender
Student*
Over-age disabled child**
* A student is a child age 21 or over but under age 25, who is a full-time student attending an educational institution recognized by Canada Revenue Agency, as long as the child is not married or in any other formal union and is entirely dependent on you for financial support (For Quebec plan members, please check with your plan administrator for dependent student age limit.)
** To enrol an over-age disabled child, complete a Disabled Child Coverage form, and send it to us within 31 days of the date the dependent reaches the age limit.

7 Beneficiary nomination

Beneficiary for Employee BASIC Life and Accidental Death Benefits (if applicable)
You must initial any changes or deletions. Correction fluid cannot be used.
Appointment beneficiary's date of birth
Appointment beneficiary's date of birth
Appointment beneficiary's date of birth
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check the revocable box.
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check the revocable box.
A revocable nomination can be changed at any time without the beneficiary’s consent. You cannot change an irrevocable beneficiary nomination unless certain requirements are met.
If you do not nominate a beneficiary, the proceeds will be paid to your estate.
If you are nominating a beneficiary who is a minor, please see section 9.

8 Appointing contingent beneficiaries – please complete this section if you wish to appoint a contingent beneficiary

If there are no surviving beneficiaries at the time of my death, I declare that the following Contingent Beneficiaries shall receive the proceeds. If there are no surviving Contingent Beneficiaries at the time of my death, the proceeds shall be paid to my estate. Unless I specify otherwise, my Contingent Beneficiary will apply to all my benefits.
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check the revocable box
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you check the revocable box

9 Nomination of trustee for minor beneficiary other than Quebec residents

If you wish to designate minor children as beneficiaries, a trustee must be designated.
Any payments becoming due while the beneficiary(s) are a minor* are to be made to
as trustee, or failing such trustee to the duly appointed guardian of such minor child as trustee. Payment to the trustee will discharge the company.
* A minor is a child who has not reached the age of majority as defined by provincial legislation.
NOTE: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on his/ her behalf.

10 Authorization and signature – you must sign and date the form

I am authorized to disclose information about my spouse and dependents in order to enrol them in the plan. By enrolling in this plan, I authorize the following:
• Sun Life Assurance Company of Canada and its reinsurers to collect, use and disclose relevant information about me to underwrite, administer, adjudicate and deposit claim payments,
• My plan sponsor to use the information collected in this form for benefits administration and to make any necessary payroll deductions which may be required,
• Sun Life Assurance Company of Canada and my plan sponsor to collect, use and disclose information about me, my spouse and dependents necessary for enrolment and for the purposes of continuing administration of the plan.
I declare that the information above is accurate and true.
A photocopy or electronic version of this authorization is as valid as the original. A photocopy or electronic version of this form is not valid for recording beneficiary nominations.
Date (yyyy-mm-dd)(Required)
This field is for validation purposes and should be left unchanged.

Grandeur Beneficiary Form

Grandeur Beneficiary Form

BENEFICIARY INFORMATION – ALL INFORMATION IS REQUIRED

I hereby assign the following individual(s) as my beneficiary. Your beneficiary will automatically default to your “ESTATE” if you fail to complete this section. Unless Otherwise Stipulated Or Prohibited By Law, The Designation Is Revocable. If The Beneficiary Is Shown As Irrevocable, His/Her consent is required to change it.
Appointment beneficiary's Last name
Appointment beneficiary's first name
Appointment beneficiary's date of birth
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change.
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change
Note: If beneficiary is shown as irrevocable, his/her consent is required to change it. Include a signed and dated consent with this form. You are responsible for ensuring the validity of your designation.
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
TRUSTEE DESIGNATION: This section is to be completed only if the beneficiary designated above is under the age of majority

DECLARATION & AUTHORIZATION – MUST SIGN AND DATE

I disclose the person name(s) under Beneficiary Designation as the appointed Beneficiary (s). I confirm that the information provided on this form is true and complete, and understand that if any of the information is incomplete or false my benefits can be terminated. I acknowledge that I am authorized to disclose and receive information about my spouse and/or dependents. the Plan Administrator, its agents, insurers and service providers are authorized to use and exchange information on this form to underwrite, administer, determine eligibility and adjudicate claims. I understand that Personal Information collected with this Application for Insurance is confidential and will not be used or any purpose other than in conjunction with this request form, and subsequent administration of, the Group Insurance protection that is afforded to Applicants, Spouses, and Dependent Children under this plan. I authorize the Plan Administrator to recover any payments made in error.
MM slash DD slash YYYY

PRIVACY & CONFIDENTIALITY

We protect our Customers’ confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents’ benefits. In terms of telephone inquiries to the Plan Administrator, Customer Service, the information provided varies based on the relationship of the person making the inquiry to the insured (e.g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only the information pertaining to the specific claim or treatment in question is shared.

EMPLOYER AUTHORIZATION – MUST SIGN AND DATE

I declare that the information provided above is accurate and true, and hereby authorize the Plan Administrator to use this information to administer the Group Benefits; obtain quotes for underwritten/insured products within the plan; verify the identity and eligibility of the plan member, spouse or eligible dependents; adjudicate and pay eligible claims; audit plans and prepare reports. I understand that this information will only be provided to those insurers affiliated with the Plan Administrator and acknowledge that I have obtained the consent of this Employee and Spouse/Partner to provide this information.
MM slash DD slash YYYY

GROUP ENROLMENT FORM

Grandeur Group Enrollment Form

EMPLOYMENT INFORMATION [TO BE COMPLETED BY YOUR PLAN ADMINISTRATOR] – COMPLETE ALL SECTIONS

MM slash DD slash YYYY
SALARY TYPE
APPLY WAITING PERIOD

EMPLOYEE INFORMATION [PLAN AND IDENTIFICATION NUMBERS ARE ASSIGNED ONCE ENROLMENT IS COMPLETED]

GENDER
MM slash DD slash YYYY
MARITAL STATUS
LANGUAGE
DEPENDENT COVERAGE REQUIRED
D/M/YYYY
GENDER:
D/M/YYYY
GENDER:
D/M/YYYY
GENDER:
D/M/YYYY
GENDER:
D/M/YYYY
GENDER:
If you or your spouse are covered for extended health care and/or dental care benefits by another plan please indicate coverage type:
Extended Health Care:
If you or your spouse are covered for extended health care and/or dental care benefits by another plan please indicate coverage type:
Dental:

REFUSAL OF EXTENDED HEALTH AND DENTAL BENEFITS

If You Or Your Dependents Are Presently Covered For Extended Health And/Or Dental Benefits Under Another Group Insurance Program You May Refuse Coverage By Selecting The Appropriate Boxes

I Refuse Coverage For Myself, My Spouse And My Dependents
I Refuse Coverage For Myself, My Spouse And My Dependents

I Refuse Coverage For My Spouse And Dependents

Hidden
I Refuse Coverage For My Spouse And Dependents

I Refuse Coverage For My Spouse And Dependents

I Refuse Coverage For My Spouse And Dependents

BENEFICIARY INFORMATION – ALL INFORMATION IS REQUIRED

Beneficiary Information:

I hearby assign the following individual(s) as my beneficiary. Your beneficiary will automatically default to your "Estate" if you fail to complete this section. Unless otherwies stipulated or prohibited by law, the designation is Revocable. If the Beneficiary is shown as Irrevocable, his/her consent is required to change it. All Beneficiary Information is Required:

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change.
If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change
Note: If beneficiary is shown as irrevocable, his/her consent is required to change it. Include a signed and dated consent with this form. You are responsible for ensuring the validity of your designation.
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:
TRUSTEE DESIGNATION: This section is to be completed only if the beneficiary designated above is under the age of majority

DECLARATION & AUTHORIZATION – MUST SIGN AND DATE

I disclose the person name(s) under Beneficiary Designation as the appointed Beneficiary (s). I confirm that the information provided on this form is true and complete, and understand that if any of the information is incomplete or false my benefits can be terminated. I acknowledge that I am authorized to disclose and receive information about my spouse and/or dependents. the Plan Administrator, its agents, insurers and service providers are authorized to use and exchange information on this form to underwrite, administer, determine eligibility and adjudicate claims. I understand that Personal Information collected with this Application for Insurance is confidential and will not be used or any purpose other than in conjunction with this request form, and subsequent administration of, the Group Insurance protection that is afforded to Applicants, Spouses, and Dependent Children under this plan. I authorize the Plan Administrator to recover any payments made in error.
MM slash DD slash YYYY

PRIVACY & CONFIDENTIALITY

We protect our Customers’ confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents’ benefits. In terms of telephone inquiries to the Plan Administrator, Customer Service, the information provided varies based on the relationship of the person making the inquiry to the insured (e.g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only the information pertaining to the specific claim or treatment in question is shared.

EMPLOYER AUTHORIZATION – MUST SIGN AND DATE

I declare that the information provided above is accurate and true, and hereby authorize the Plan Administrator to use this information to administer the Group Benefits; obtain quotes for underwritten/insured products within the plan; verify the identity and eligibility of the plan member, spouse or eligible dependents; adjudicate and pay eligible claims; audit plans and prepare reports. I understand that this information will only be provided to those insurers affiliated with the Plan Administrator and acknowledge that I have obtained the consent of this Employee and Spouse/Partner to provide this information.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

Values

White heart icon on a blue circle.

Loyalty

White school building icon on blue circle.

Benefits Industry Education

White handshake icon on blue circle.

Serving

Reach out to us now for exceptional Group Benefits and insurance industry services.

Connect Today