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4 | Authorization and Signature – you must complete this section
I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable.
I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid
for by this or any other plan.
If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them,
for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if
any, also authorize Sun Life Assurance Company of Canada (“Sun Life”) to disclose information about their claims to me, for
the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.
I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse and/
or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other organization
who has relevant information pertaining to this claim including health professionals, institutions, investigative agencies and
insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan is audited.
In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree
that Sun Life may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be
used and disclosed to any relevant organization including regulatory bodies, government organizations, medical suppliers
and other insurers, and where applicable my Plan Sponsor, for the purpose of investigation and prevention of fraud and/or
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to
me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or
organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect
for the continued administration of this Plan.
Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.
Respecting your privacy
Respecting your privacy is a priority for the Sun Life Financial group of companies. We keep in confidence personal information about you
and the products and services you have with us to provide you with investment, retirement and insurance products and services to help you
meet your lifetime financial objectives. To meet these objectives, we collect, use and disclose your personal information for purposes that
include: underwriting; administration; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal, regulatory
or contractual requirements; and we may tell you about other related products and services that we believe meet your changing needs.
The only people who have access to your personal information are our employees, distribution partners such as advisors, and third-party
service providers, along with our reinsurers. We will also provide access to anyone else you authorize. Sometimes, unless we are otherwise
prohibited, these people may be in countries outside Canada, so your personal information may be subject to the laws of those countries.
You can ask for the information in our files about you and, if necessary, ask us in writing to correct it. To find out more about our privacy
practices, visit www.sunlife.ca/privacy.
Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 Monday - Friday, 8 a.m. - 8 p.m. ET
Mailing instructions – keep a copy of your claim form and receipts for your records
Mail your completed
form to the claims
office nearest you.
Sun Life Assurance Company
PO Box 11658 Stn CV
Montreal QC H3C 6C1
Sun Life Assurance Company
PO Box 2010 Stn Waterloo
Waterloo ON N2J 0A6
For SLF use: