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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br />Sun Life Assurance Company of Canada <br />Employer Information form <br />Sun Life Assurance Company of Canada and wholly owned Prepaid Dental companies are referred to as “Sun Life” <br />throughout this form. <br /> Your company information <br />Full legal name of employer (to appear on contract/policy documents and in the Maxwell platform) <br /> <br />Employer Tax ID Number <br />Do you qualify for a sales tax exemption? ......................................................................................................... Yes No <br />If “Yes,” please provide applicable documentation (i.e. sales tax exemption certificate) <br />Please provide your company’s logo to be displayed in the Maxwell platform (.png,.jpg, or .jpeg format) <br />Are you currently insured with a Sun Life company for Life, Disability, Worksite, Dental or Vision? ................ Yes No <br />If “Yes,” please provide the policy numbers: ___________________________________________ <br />Our goal is to help you achieve your goals. Tell us about why you chose Maxwell + Sun Life: <br />Previous coverage information <br />Please indicate below which Sun Life benefit(s) will replace your current coverage at another carrier. <br />A copy of the prior carrier contract and prior carrier bill is required for each benefit selected below. <br /> Life <br /> Accidental Death & Dismemberment (AD&D) <br /> Voluntary Life/AD&D <br /> Short-Term Disability <br /> Voluntary Short-Term Disability <br /> Paid Family and Medical Leave (PFML) - Please provide states this is inforce for: _______________________ <br /> Long-Term Disability <br /> Voluntary Long-Term Disability <br /> Dental <br /> Vision <br /> Critical Illness <br /> Accident <br /> Cancer Indemnity <br /> Hospital Indemnity <br />Information contained in the prior carrier contract is essential to help protect your employees’ benefit levels and minimize <br />claims issues during a change of insurer. The prior carrier contract also helps us configure your plan accurately when <br />transitioning to your new group policy. <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />X <br />X <br />942727 <br />X <br />City of Everett <br />X <br />X