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GVMPAP-5644 (WA) (Rev 2/20) Application for Group Insurance 2 of 3 <br />3| Terms of agreement <br />The Applicant hereby applies for Group Insurance as specified in the Sun Life Assurance Company of Canada (Sun Life) <br />proposal. The undersigned Applicant has read, understands and agrees that: <br />1.The insurance requested in this Application for Group Insurance will not become effective until it has been approved <br />by Sun Life. <br />2.The requested group insurance will: <br />•be issued only if the requested insurance is accepted by Sun Life and is legally permissible; <br />•be issued under a Group Policy or Policies in the language customarily used by Sun Life; <br />•be subject to Sun Life’s standard underwriting requirements; and <br />•take effect on the date determined by Sun Life. <br />3.All information given in connection with this Application for Group Insurance is true and complete to the best of the <br />Applicant’s knowledge, information and belief. <br />4.Premium rate quotes are based on the data previously submitted to Sun Life. Final premium rates will be determined <br />based on the final census submitted. Sun Life reserves the right to re-rate any coverage retroactively to the effective <br />date or take other appropriate actions if any information provided to us is not true or is incomplete. <br />5.If Sun Life approves an Applicant’s request for group insurance coverage, employees who are not actively at work on <br />the group insurance policy’s effective date will only be insured if they satisfy the policy’s “Continuity of Coverage” <br />provision or are required to be covered by law. <br />6.No producer, agent or broker can make or modify a contract for Sun Life and all coverage will be as stated in Sun Life <br />policies. No agent or broker has the authority to guarantee the acceptability of the requested insurance. <br />7.When you purchase insurance from us, we pay compensation to the producer and/or to the agency through which the <br />producer works. If the producer works through an agency, the agency may pay compensation directly to the producer. <br />Compensation may include commissions when a policy is purchased or renewed, and fees for other services. The <br />compensation may vary by the type of insurance purchased. Additionally, bonuses and incentive trips or awards <br />associated with sales may be paid based on the overall sales volume or persistency of business. The compensation <br />that we pay to producers may differ from that paid by other insurance companies. If you have questions, contact your <br />producer directly. <br />8.This Application is made a part of the Group Policy. <br />4 | Authorization <br />I acknowledge that I have read or had read to me and understand the Terms of Agreement above and the Fraud Warning <br />for my state. <br />It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of <br />defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. <br />Name and title of Applicant organization’s Authorized Representative <br />Signature of Authorized Representative <br />X <br />Place of signing Date <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />Cassie Franklin, Mayor <br />Everett, WA 12/10/2024