Service Office: One Sun Life Executive Park, Wellesley Hills, MA 02481
Sun
Life Insurance and Annuity Company of New York
|
Service
Office: One Sun Life Executive Park, Wellesley Hills, MA
02481
|
Company/Owner
Name
______________________________________________________________________________
The
Company/Owner listed above (the “Owner”) intends to purchase a life insurance
policy or policies on the life of the Proposed Insured listed
below. In advance of any policy issuance [or material increase], the
Proposed Insured will be notified in writing of the maximum total amount of
insurance to be purchased at the time the policy or policies are
issued.
CONSENT
TO PURCHASE OF INSURANCE
I
hereby consent to the purchase of life insurance on my life by the Company/Owner
(the “Owner”) listed above and in accordance with the Master Application for
Corporate Life Insurance which is incorporated as part of this consent. I
acknowledge that the policy or policies so purchased may remain in force after
my termination of employment from the Owner. I understand that the Owner
will be the owner and beneficiary of the policy or policies, and that any
benefits from such life insurance are payable to the Owner. Neither I, my heirs,
assignees, estate, nor administrators have any ownership or beneficial interest
or rights in the policy or policies or in any policy proceeds, unless the Owner
otherwise notifies the insurer.
The
maximum amount of insurance that will be purchased on my life at the time the
policy or policies are issued is $______________.
Proposed
Insured Information
1. Proposed
Insured’s Name
________________________________________________________ 2. Male
r Female
r
3. Date
of Birth ______ - ______ -
_____
4. Age
______ 5.
Social Security Number ______ - ______ - ______
QUESTIONS
6. During
the past 3 months, have you, the Proposed Insured, been actively at work on
a
full-time basis,
at
least 30 hours per week in a normal capacity, and not been absent for more
than
five consecutive
days
due to illness or medical
treatment? YES r NO r
If
no, give details:
_____________________________________________________________________________
______________________________________________________________________________
7. Have
you, the Proposed Insured, used tobacco (cigarettes, cigars, chewing tobacco,
pipe, etc.) or any other
substance
containing nicotine, including Nicorette gum, within the past twelve
months?
If
yes, please list type
and number of each product used per
day: YES r NO
r
_______________________________________________________________________________
8. In
the past 10 years, have you, the Proposed Insured, been treated
for:
Any
disorder of the heart or blood vessels, tumor or cancer, diabetes, stroke,
or
any disorder of the
blood,
lungs, kidneys, drug or alcohol use, depression or been diagnosed or treated
by
a doctor or
other
medical practitioner for Human Immunodeficiency Virus or Acquired Immune
Deficiency
Syndrome
(AIDS)? YES r NO
r
If
yes, give
details:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
AGREEMENT
I
agree that all statements and answers in this consent form are true and complete
to the best of my knowledge and belief. This
consent
form shall be attached to and form a part of any policy of insurance
issued. [As long as I continue to work for the Owner,
the
Insurer
can change the Amount of Insurance in accordance with the Owner’s written
request to change such Amount. Each change
shall
be subject to the Insurer’s underwriting limitations and requirements then in
effect, including but not limited to my being
actively
at work at the time of the change].
Signature
of Proposed
Insured: _________________________________________________________ Date:
___________________
2007
SCOLI Consent
XGI Page
of
[INSERT
PAGE NUMBER]
