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Domiciliary State – Michigan <br />GVMPAP-5644 (WA) (Rev 2/20) Application for Group Insurance 1 of 3 <br />Sun Life Assurance Company of Canada <br />One Sun Life Executive Park, Wellesley Hills, MA 02481 <br />Application for Group Insurance <br /> <br /> <br />1 | Applicant organization information <br /> <br />Full legal name (As it is to be shown in the Group Policy) <br /> <br />Main office address <br /> <br />City <br /> <br />County <br /> <br />State <br /> <br />Zip code <br /> <br /> <br />Type of Organization: Corporation S Corporation Partnership Sole Proprietor LLC/LLP <br />Subsidiaries or Affiliates to be Included. An affiliate or subsidiary is a separate firm owned or controlled by the Applicant. <br />1. Legal name <br /> <br />Street address <br /> <br />City <br /> <br />State <br /> <br />Zip code <br /> <br /> <br />2. <br /> <br />Legal name <br /> <br />Street address <br /> <br />City <br /> <br />State <br /> <br />Zip code <br /> <br /> If you need more space, check here and attach a separate page. <br /> <br />2 | Requested insurance information <br /> <br />If any requested coverage is to have a different effective date than the date indicated at right, please note the effective <br />date next to the coverage. <br />Requested effective date (mm/dd/yy) <br /> <br /> <br /> Life <br /> Accidental Death & Dismemberment <br /> Voluntary Life/AD&D <br /> Long-Term Disability <br /> Short-Term Disability <br /> Customized Disability <br /> Dental <br /> Vision <br /> Critical Illness <br /> Cancer <br /> Accident <br /> Hospital Indemnity <br /> Other ___________________________ <br /> <br /> <br /> <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />WA <br />X <br />X <br />X <br />01/01/25 <br />X <br />Everett 98201 <br />2930 Wetmore Ave, 5th Fl <br />City of Everett <br />X