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Contact us <br />By mail <br />Sun Life Assurance Company of Canada <br />One Sun Life Executive Park <br />Wellesley Hills, MA 02481 <br />www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET <br />GVMPAP-5644 (WA) (Rev 2/20) Application for Group Insurance 3 of 3 5/16 <br />5 | Producer information <br />The following information must be fully completed and signed before processing can be completed. Box Number 2 should <br />only be completed if a Commission split has been approved. <br />1. Individual Agency Broker’s Broker Commission split <br />Name of Agent/Broker/Agency (Please print legal name) <br /> <br />Agent/Broker license no. <br />Street address City State Zip code <br />Email address Phone number <br />Signature of Agent/Broker <br />X <br />Date <br />Countersigned by licensed resident agent (where required by law) <br />X <br />Agent license no. <br />2. Individual Agency Broker’s Broker Commission Split ` <br />Name of Agent/Broker/Agency (Please print legal name) Agent/Broker license no. <br />Street address City State Zip code <br />Email address Phone number <br />Signature of Agent/Broker <br />X <br />Date <br />Countersigned by licensed resident agent (where required by law) <br />X <br />Agent license no. <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />Alliant Insurance Services Inc <br />401 Union St. 31st Floor Seattle WA 98045 <br />Alliant <br />britt.wooldridge@alliant.com 310-606-0378 <br />11/20/2024