Sun Life Assurance Company of Canada 12/10/2024

GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 Authorization and signature The undersigned employer has read, understands, and agrees that: 1.The requested group insurance will: •be issued only if the requested insurance is accepted by Sun Life and is legally permissible (cashing of the initial deposit check or processing initial deposit payments does not constitute approval of the requested insurance); •be issued in the language customarily used by Sun Life; •be subject to Sun Life’s standard underwriting requirements; and •take effect on the date determined by Sun Life. 2.All information given in connection with this Employer Information form is true and complete to the best of the employer’s knowledge, information, and belief. Employer agrees to supplement and correct information provided in writing. If any information given on this form differs from what is given on the Application for Group Insurance, the terms of the Application for Group Insurance will control. 3.The receipt of premium by Sun Life is not a guarantee of coverage. Eligibility for benefits will be determined at the time of claim submission. Employer should not pay or collect premiums for or from employees who are not eligible for coverage. Employer will not collect premiums for coverage subject to Evidence of Insurability before such Evidence has been approved by Sun Life. Employer acknowledges and agrees that it will be responsible for confirming eligibility of spouses and dependents and for notifying Sun Life if any spouses and dependents are not eligible for coverage. 4.Employees not Actively at Work on the effective date agreed to by Sun Life will be identified to Sun Life and will be insured only as required by law or as approved in writing by Sun Life. No producer, agent, or broker can make or modify a contract for Sun Life, and all coverage will be as stated in Sun Life policies. No agent or broker has the authority to guarantee the acceptability of the requested insurance. 5.Employer agrees not to alter any NAIC publication provided by Sun Life, to limit distribution to its employees, to distribute only the most current version as supplied by Sun Life and not to receive any compensation for its use. Employer acknowledges any NAIC publication is the exclusive property of the NAIC and will take no action adverse to those rights. Employer will dispose of any copies of NAIC publications supplied by Sun Life when its group insurance with Sun Life terminates. 6.Electronic Transactions: Pursuant to the terms of the Client and Consumer Electronic Consent and Disclosure, the undersigned employer consents to electronic transactions, including transactions involving membership and billing, premium payment, Evidence of Insurability, claims (where applicable), and electronic delivery of application and policy documents. The employer may at any time opt out of electronic transaction, or at no additional charge obtain a paper copy of any document or notice that has been delivered or made available electronically by request to the Company. See Client and Consumer Electronic Consent and Disclosure for information about how to opt out and request paper copies. Kentucky only: The employer authorizes Sun Life at its discretion to communicate cancellations, renewals, premium increase and to deliver policy documents, group application and related forms electronically by the web portal and DocuSign. The employer is aware that this election operates as consent for all notices to be sent electronically; therefore, the employer should be diligent in updating the electronic mail address provided to the insurer. The policyholder may, at its option, request Sun Life to provide paper copies of the policy and all notices; or to receive the policy electronically and all notices in paper copy; or to receive the policy and all notices electronically. For electronic transactions through DocuSign, employer may download and print documents it received from Sun through the DocuSign system during and immediately after the signing session. If employer elects to create a DocuSign account, it may access the documents for a limited period of time (usually 30 days) after such documents are first sent to Employer. After such time, if you wish for us to send you paper copies of any such documents from our office to you. To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must reach out to your Sun Life Service representative. We will bill you for any fees at that time, if any. Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65