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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br /> Contract and administrative options for Sun Life benefits <br />NOTE: For Paid Family Medical Leave, please see specific product page for eligibility and waiting period. <br />A.Eligibility: Eligible employees must be working at the employer’s usual place of business. <br />•Employer paid products typically have 30 hours per week minimum required: <br />•Employee paid products typically have 20 hours per week minimum required. <br />•Employees not regularly working at least 20 hours per week are considered part-time. <br />Employees not actively at work are not covered until they return to work, unless required by applicable state law or <br />approved in writing by the Sun Life Underwriting department. <br />Eligible employees: <br /> All full-time U.S. employees working in the U.S. and scheduled to work 30 hours. (most common) <br /> Other: ___________________________________________________________________________________ <br /> Differs by class: ___________________________________________________________________________ <br />___________________________________________________________________________________________ <br /> Differs by benefit: __________________________________________________________________________ <br />___________________________________________________________________________________________ <br />(May require Home Office approval.) <br />Number of employees eligible for Sun Life coverage __________ <br /> If differs by coverage, please specify: _____________________________________________________ <br />Are union members being covered? .................................................................................................................. Yes No <br />Are domestic partners being covered? ..................................................................................................... Yes No <br />B.Eligibility waiting period for Sun Life benefits: This is the amount of time required after employees are hired before <br />they are eligible for benefits. Applies to all Sun Life lines of coverage unless otherwise noted. <br />Please fill in the option below that meets your needs. <br /> First of the month following* <br /> Date of hire 30 days 45 days 60 days 90 days 3 months <br />Is this coinciding or not coinciding?* Coinciding Not coinciding <br />Does this waiting period apply to all employees and lines of coverage? .................................. Yes No <br />If “No,” please specify: _____________________________________________________ <br /> Date of Hire plus <br /> None 30 days 45 days 60 days 90 days 3 months Other__________ <br />Does this waiting period apply to all employees and lines of coverage? .................................. Yes No <br />If “No,” please specify: _____________________________________________________ <br />*Prepaid Dental must have a waiting period that contains first of the month following <br />*Critical Illness, Cancer Indemnity, Accident and Hospital Indemnity typically has a waiting period that contains first of <br />the month following to allow time to set up payroll deductions <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />X <br />are NOT eligible for Life, AD&D, Dep Basic Life, Voluntary Life or LTD <br />X <br />See below <br />X <br />X <br />X <br />FT & PT scheduled for at least 22 hpw. LTD is only offered to Appointive EEs. EPOA, DPMA & Fire <br />X LTD = 253 All Other Benefits = 830 <br />X <br />X