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Sun Life Assurance Company of Canada (Cape Fear Community College)

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XGR/1641 LTD Claim Packet - Claimant Page 1 of 12
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant
Instructions for the Claimant
Please mail all
documents 4
-6 weeks
before the end of your
elimination period.
Please make sure to initiate the Long Term Disability claim filing process as soon as it first appears
that
your disability will extend beyond the required elimination period. Please refer to your
group insurance policy to determine the length of the elimination period.
It is the responsibility of the claimant
to ensure that the Employer’s Statement and the
Attending Physician
’s Statement are submitted directly to Sun Life Financial.
Please be sure to submit the Employe
e’s Statement directly to Sun Life Financial.
The Employee must:
Sign and date the Employee’s Statement
Sign and date the Authorizations
Sign and date the Reimbursement Agreement
Have the employer complete and return the Employer’s Statement to Sun Life Financial
Have the physician complete and return the Attending Physician’s Statement to Sun
Life Financial
Attach a copy of a photo ID (i.e., license or passport)
Attach a detailed job description (from employer)
Mail or fax the completed claim form to:
Sun Life Assurance Company of Canada
Group Long Term Disability Claims
P.O. Box 81830
Wellesley Hills, MA 02481
Fax: (781) 304
-5537
Failure to provide complete and accurate information could result in the need for additio
nal
claims investigation which could delay the initial benefit payment.
919310
XGR/1641 LTD Claim Packet - Claimant Page 2 of 12
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant
State law requires that we notify you of the following:
General f
raud warning: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading, informati
on concerning
any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
AK
: A person who knowingly and with intent to injure, defraud, or deceive an insurance
company files a cl
aim containing false, incomplete, or misleading information may be
prosecuted under state law.
AL:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application
for insurance is guilty of a
crime and may be subject to restitution fines or confinement in prison, or any combination
thereof.
AR, LA, MA, MN,
RI, TX, and WV: Any person who knowingly presents a false or fraudulent
claim for payment of a loss or bene
fit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ
: For your protection Arizona law requires the following statement to appear on this form. Any
person
who knowingly presents a false or fraudulent claim for payment of a loss is subject to
criminal and civil penalties.
CA
: For your protection California law requires the following to appear on this form: Any person
who knowingly presents a false or fraudul
ent claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in state prison.
CO
: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of d
efrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or inform
ation to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or
award payable from insurance proceeds shall be reported to the Colorado Division of Insurance
within the
Department of Regulatory Agencies.
DC
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime
and may be subject to fines a
nd confinement in prison.
DE, ID, and IN
: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, files a statement of claim containing any false, incomplete or misleading information is
guilty of a felony.
FL
: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information
is guilty of a felony of the third degree.
KS
: Any person who knowingly and with intent to defraud any insurance company or other
person files an Application for insurance or statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material
thereto may be guilty of insurance fraud as determined by a court of law.
919310
XGR/1641 LTD Claim Packet - Claimant Page 3 of 12
Claimant:
DOB:
Policy no.:
CC no:
KY
: Any person who knowingly and with intent to defraud any insurance company or other
person files a statement of claim containing any materially false information
or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime.
MD:
Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a
loss or benef
it or who knowingly OR willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
ME: It is a crime to knowingly provide false, incomplete or misleading information to a
n
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
NH
: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files
a statement of claim cont
aining any false, incomplete, or misleading information is subject to
prosecution and punishment for insurance fraud, as provided in RSA 638:20.
NJ
: Any person who knowingly files a statement of claim containing any false or misleading
information is subje
ct to criminal and civil penalties.
NM:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime
and may be subject to
civil fines and criminal penalties.
OH
: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty
of insurance fraud.
OK
: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
OR and VA
: Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive
statement may have violated state law.
PR
: Any person who knowingly and with the intention of defrauding presents false information in
an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for
the payment of a loss or any other benefit, or presents more than one claim for the same
damage or loss, shall incur a fe
lony and, upon conviction, shall be sanctioned for each violation
by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should
agg
ravating circumstances be present, the penalty thus established may be increased to a
maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
TN and WA:
It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
VT
: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
919310
XGR/1641 LTD Claim Packet - Claimant Page 4 of 12
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant
Employee’s Statement
Please print clearly.
Return to
:
Sun Life Assurance
Company of Canada
Group LTD Claims,
SC
4328
1 Sun Life Exec. Park
P.O. Box 81830
Wellesley Hills, MA 02481
Fax:
(781) 304-5537
Name of employee (first, middle initial, last)
M
F
Social Security number
Group policy number
Street address
City
State
Zip Code
Occupation
Date of birth
Phone number
Marital status
Spouse’s name (first, middle initial, last)
Social Security number
Date of birth
Is your spouse employed ........................................................................................................ Yes No
Names and dates of birth of your children (under age 25)
If a motor vehicle
accident has occurred and
is the cause of the
disability, a motor vehicle
accident report
is required to be included
with this statement.
Date of accident or date you first noticed symptoms of your illness
Describe in detail how, when and where the accident occurred –OR – Describe the nature of your
illness/condition and its first symptoms.
Is your condition due to injury or sickness related to your job?.............................................. Yes No
If yes, please explain below.
Date you were first treated by a physician
Last date worked prior to disability
Did you work Yes
a full day? No
Date first unable to work
Have you returned to work?
Yes No If yes, Date: With restrictions Full capacity
If work-related, have you filed/do you intend to file, a Workers’ Compensation claim? Yes No
If yes, provide date:
If you need more space,
check
here
and attach
a separate page.
Name of physician
Specialty
Address
Telephone number
Fax number
Date of last visit
Date of next visit
Have you discussed a return to work plan with this physician? ........................................... Yes No
919310
919310
XGR/1641 LTD Claim Packet - Claimant Page 5 of 12
Claimant:
DOB:
Policy no.:
CC no:
Name of physician
Specialty
Address
Telephone number
Fax number
Date of last visit
Date of next visit
Have you discussed a return to work plan with this physician? ........................................... Yes No
If you need more space,
check
here
and attach
a separate page.
1.
Name of hospital
Telephone number
Dates of confinement
to
2.
Name of hospital
Telephone number
Dates of confinement
to
Are you currently receiving, or entitled to receive, benefits from any of the following sources?
Source of income
Amount of each
payment
Weekly or
monthly?
Period/date(s)
covered by
payment
Check all that apply
and provide
award/denial notice
or application
associated with any
source of income.
Sick Pay
$
Wkly Mthly
Salary Continuance
$
Wkly Mthly
State Disability
$
Wkly Mthly
Workers’ Compensation
$
Wkly Mthly
Unemployment Compensation
$
Wkly Mthly
Social Security Disability/Retirement
$
Wkly Mthly
Disability/Retirement Pension
$
Wkly Mthly
Automobile No-fault Insurance
$
Wkly Mthly
Union Disability
$
Wkly Mthly
Severance
$
Wkly Mthly
Other:
$
Wkly Mthly
6 Education and Training Information
Please indicate your highest level of education completed.
Less than High School (Grade: ) High School (GED) College
Name of school / college
Degree
Dates attended
Field of study
Additional Course Work, Education, Training, Special Skills and/or Hobbies
Military Experience
Did you serve in the armed forces? ........ Yes No
Branch of service
Highest rank
Dates of service
to
Specialty
919310
XGR/1641 LTD Claim Packet - Claimant Page 6 of 12
Claimant:
DOB:
Policy no.:
CC no:
If you have a resume,
please attach a copy.
You may use this
section to indicate any
additional experience.
Work Experience
Please list chronologically all of the jobs you have held. Start with your current or most recent job.
Provide as many details as possible.
Name of Employer
Title
Dates of employment
to
Department
Tasks and duties (please be specific)
Name of Employer
Title
Dates of employment
to
Department
Tasks and duties (please be specific)
Name of Employer
Title
Dates of employment
to
Department
Tasks and duties (please be specific)
Skills Development
What, if any, training or education would you be interested in pursuing?
8 Checklist of Required Attachments
Please mail all documents 4-6 weeks before the end of your elimination period. Failure to provide
the following information could result in a delay
of the initial benefit payment.
Sign and date the Employee’s Statement
Sign and date the Authorizations
Sign and date the Reimbursement Agreement
Employer completed and returned the Employer’s Statement
Physician completed and returned the Attending Physician’s Statement
Attach a copy of a photo ID (i.e., license or passport)
We
will contact you as soon as we have received and reviewed your claim forms and medical records. In
the meantime, should you have any questions, please
call our Customer Service Center
at 1-800-247-6875.
Reminder: Please be
sure to sign and return
any Authorization
statements included
in this packet.
I certify that the above statements are true and complete. I have read or had read to me the fraud
warning for my state.
Employee’s signature
X
Date signed
919310
XGR/1641 LTD Claim Packet - Claimant Page 7 of 12
Claimant:
DOB:
Policy no.:
CC no:
This page left blank intentionally
919310
XGR/1641 LTD Claim Packet - Claimant Page 8 of 12
Claimant: DOB: Policy no.: CC no:
Sun Life Assurance Company of Canada
Authorization
Authorization for Release and Disclosure of Health Related Information
This Authorization complies with the HIPAA Privacy Rule.
It is important for you to read, sign and submit all Authorizations in this packet. Failure to submit all Authorizations could
result in a delay during the claims process.
I HEREBY AUTHORIZE any physician, healthcare provider, health plan, medical professional, hospital, clinic, laboratory,
pharmacy benefit manager or other medical or healthcare facility that has provided payment, treatment or services to me or on
my behalf to disclose my entire medical record and any other protected health information concerning me to the Claims
Department of Sun Life Assurance Company of Canada (“the Company”), its subsidiaries, affiliates, third party administrators
and reinsurers.
I understand that such information may include records relating to my physical or mental condition such as diagnostic tests,
physical examination notes and treatment histories, which may include information regarding the diagnosis and treatment of
human immunodeficiency virus (HIV) infection, sexually transmitted diseases, mental illness and the use of alcohol, drugs and
tobacco, but shall not include psychotherapy notes.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply
to this Authorization, and I instruct any physician, healthcare professional, hospital, clinic, medical facility or other healthcare
provider to release and disclose my entire medical record without restriction.
I understand that the Company may use the information it obtains to: (a) underwrite my application for coverage; (b) make
eligibility, risk rating, policy issuance and enrollment determinations; (c) obtain reinsurance; (d) administer claims and determine
or fulfill responsibility for coverage and provision of benefits; (e) administer coverage; (f) assist my employer in reviewing and
evaluating requests for statutory leaves and/or accommodations as part of the interactive process under the Americans with
Disabilities Act or other applicable laws; and/or (g) conduct other legally permissible activities that relate to any coverage I have
or have applied for with the Company, including but not limited to any request for leave or workplace accommodation.
I authorize the Company to disclose information it obtains about me to the following persons to the extent necessary for the
recipient to provide claim management or advisory services, to audit the administration of claims, or to verify, evaluate and/or
adjudicate my claim: (a) my employer, its agents, and any plan sponsor, administrator or other service provider of any benefit
plan in which I participate or leave/accommodation services associated with my employment; (b) my treating physicians,
psychologists and therapists/counselors; (c) other persons or organizations performing medical, investigative, financial or legal
services related to my claim; (d) my insurer, if the Company is acting only as the administrator of my claim and; (e) other
insurance companies, third party administrators or insurance support organizations to prevent fraud or material nondisclosure in
connection with insurance transactions. The Company will not disclose information it obtains about me except as authorized by
this Authorization, as may be required or permitted by law; or as I may further authorize. I understand that if information is re-
disclosed as permitted by this authorization, it may no longer be protected by applicable federal privacy law.
I understand that: (a) this Authorization shall be valid for 24 months from the date of signature; (b) I may revoke it at any time
by providing written notice to Sun Life Assurance Company of Canada, One Sun Life Executive Park, Wellesley Hills,
Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to receiving notice of its revocation;
and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original.
Print name of employee or personal representative of employee
Group policy number
If Representative, description of your authority or relationship to employee
Signature of employee or personal representative
X
Date
919310
919310
XGR/1641 LTD Claim Packet - Claimant Page 9 of 12
Claimant: DOB: Policy no.: CC no:
Sun Life Assurance Company of Canada
Authorization for Release and Disclosure of Psychotherapy Notes
I HEREBY AUTHORIZE any: physician, health care provider, health plan, medical professional, hospital, clinic, or other
medical or health care facility that has provided payment, treatment or services to me or on my behalf; to disclose any
psychotherapy notes relating to me to the Claims Department of Sun Life Assurance Company of Canada (“the Company”), its
subsidiaries, affiliates, third party administrators and reinsurers.
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply
to this Authorization, and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care
provider to release and disclose all psychotherapy notes relating to me without restriction.
I understand that the Company may use the information it obtains to: (a) underwrite my application for coverage; (b) make
eligibility, risk rating, policy issuance and enrollment determinations; (c) obtain reinsurance; (d) administer claims and determine
or fulfill responsibility for coverage and provision of benefits; (e) administer coverage; (f) assist my employer in reviewing and
evaluating requests for statutory leaves and/or accommodations as part of the interactive process under the Americans with
Disabilities Act or other applicable laws; and/or (g) conduct other legally permissible activities that relate to any coverage I have
or have applied for with the Company, including but not limited to any request for leave or workplace accommodation.
I authorize the Company to disclose information it obtains about me to the following persons to the extent necessary for the
recipient to provide claim management or advisory services, to audit the administration of claims, or to verify, evaluate and/or
adjudicate my claim: (a) my employer, its agents, and any plan sponsor, administrator or other service provider of any benefit
plan in which I participate or leave/accommodation services associated with my employment; (b) my treating physicians,
psychologists and therapists/counselors; (c) other persons or organizations performing medical, investigative, financial or legal
services related to my claim; (d) my insurer, if the Company is acting only as the administrator of my claim and; (e) other
insurance companies, third party administrators or insurance support organizations to prevent fraud or material nondisclosure in
connection with insurance transactions. I understand that the Company will not disclose information it obtains about me except
as authorized by this Authorization; as may be required or permitted by law; or as I may further authorize. I understand that if
information is re-disclosed as permitted by this Authorization, it may no longer be protected by applicable federal privacy law.
I understand that: (a) this Authorization shall be valid for 24 months from the date I sign it; (b) I may revoke it at any time by
providing written notice to Sun Life Assurance Company of Canada, One Sun Life Executive Park, Wellesley Hills,
Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to receiving notice of its revocation;
and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original.
Print name of employee or personal representative of employee
Group policy number
If Representative, description of your authority or relationship to employee
Signature of employee or personal representative
X
Date
919310
919310
XGR/1641 LTD Claim Packet - Claimant Page 10 of 12
Claimant: DOB: Policy no.: CC no:
Sun Life Assurance Company of Canada
Authorization for Release and Disclosure of Non-Health Related Information
I HEREBY AUTHORIZE any: (a) physician, healthcare provider, health plan, medical professional, hospital, clinic, laboratory,
therapist, pharmacy benefit manager or other medical or healthcare facility that has provided payment, treatment or services to
me or on my behalf; (b) benefit plan administrator; (c) employer; (d) insurance company; (e) insurance support organization; (f)
state department of motor vehicles; (g) consumer reporting agency; (h) financial institution; (i) government agency, or the
Medical Information Bureau, Inc., Social Security Administration, Internal Revenue Service or the Veteran’s Administration, to
disclose to Sun Life Assurance Company of Canada (“the Company”), its subsidiaries, affiliates, third party administrators, and
reinsurers, any and all non-health information relating to me, including, but not limited to (a) my employment earnings; (b) my
occupational duties; (c) my credit history; (d) insurance benefits I may be receiving or have received; (e) Social Security benefits
I, or my dependents, may be receiving or have received; (f) insurance claims I may have filed or insurance coverage I may have;
(g) traffic accident reports relating to me; and (h) any other financial information relating to me.
I understand that the Company may use the information it obtains to: (a) underwrite my application for coverage; (b) make
eligibility, risk rating, policy issuance and enrollment determinations; (c) obtain reinsurance; (d) administer claims and determine
or fulfill responsibility for coverage and provision of benefits; (e) administer coverage; (f) assist my employer in reviewing and
evaluating requests for statutory leaves and/or accommodations as part of the interactive process under the Americans with
Disabilities Act or other applicable laws; and/or (g) conduct other legally permissible activities that relate to any coverage I have
or have applied for with the Company, including but not limited to any request for leave or workplace accommodation.
I authorize the Company to disclose information it obtains about me to the following persons to the extent necessary for the
recipient to provide claim management or advisory services, to audit the administration of claims, or to verify, evaluate and/or
adjudicate my claim: (a) my employer, its agents, and any plan sponsor, administrator or other service provider of any benefit
plan in which I participate or leave/accommodation services associated with my employment; (b) my treating physicians,
psychologists and therapists/counselors; (c) other persons or organizations performing medical, investigative, financial or legal
services related to my claim; (d) my insurer, if the Company is acting only as the administrator of my claim and; (e) other
insurance companies, third party administrators or insurance support organizations to prevent fraud or material nondisclosure in
connection with insurance transactions. The Company will not disclose information it obtains about me except as authorized by
this Authorization, as may be required or permitted by law; or as I may further authorize. I understand that if information is re-
disclosed as permitted by this authorization, it may no longer be protected by applicable federal privacy law.
This Authorization shall apply to information relating to my dependents where applicable.
I understand that: (a) this Authorization shall be valid no longer than 24 months from the date of signature below; (b) I may
revoke it at any time by providing written notice to Sun Life Assurance Company of Canada, One Sun Life Executive Park,
Wellesley Hills, Massachusetts, 02481, subject to the rights of any person who acted in reliance on it prior to receiving notice of
its revocation; and (c) my authorized representative and I are entitled to receive a copy of the Authorization upon request.
A copy of this Authorization shall be as valid as the original.
Print name of employee or personal representative of employee
Group policy number
If Representative, description of your authority or relationship to employee
Signature of employee or personal representative
X
Date
919310
919310
XGR/1641 LTD Claim Packet - Claimant Page 11 of 12
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Claimant
Reimbursement Agreement
Return to:
Sun Life Assurance
Company of Canada
Group LTD Claims
P.O. Box 81830
Wellesley Hills, MA 02481
Fax: (781) 304-5537
I UNDERSTAND and agree that the provisions of Group Long Term Disability Policy No.
permit Sun Life Assurance Company of Canada (herein called the
“Company”) to offset
from my monthly disability benefit any benefits received from Social Security and/or Workers’
Compensation or as otherwise provided in the Group
Long Term Disability Policy. I further
UNDERSTAND
and agree that the Company may offset any such amounts that I or my dependents are
eligible to receive, whether or not I or my dependents are actually receiving said amounts.
In return for the Company’s adv
ance payment of the Long Term Disability benefits to which I may be
entitled, which
advanced amount may be in excess of the amount due to me under the terms of the
policy, I, for myself, my heirs, executors, administrators and assigns agree:
1.
That I am not currently receiving any benefits from Social Security and/or Workers’ Compensation,
and/or any Other Income benefit to which I may be eligible as described in
the policy.
2.
To apply for Social Security disability benefits and/or Workers’ Compensation benefits, and/or any
Other Income benefit to which I or my dependents may be eligible as described in the policy
.
3.
If I, and/or my spouse and family receive any disability payments, regardless of the amount, in
connection with Social Security and/or Workers’ Compensation, and/or any Other Income benefit
to which I or my spouse and family may be eligible as described in the policy; I and/or my spouse
and family will immediately notify the Company of such disability payments and will pay back all
amo
unts over and above the amounts to which I would be entitled under the policy provisions.
4.
I understand that thereafter the Company is entitled to offset any amounts received from Social
Security and/or Workers’ Compensation
, and/or any Other Income benefit to which I may be
eligible as described in the policy
with the monthly benefit payable under the policy in accordance
with the terms of the policy.
I UNDERSTAND that the Company, in reliance on the above statements and promises, has agreed
to advan
ce to me the disability benefits to which I or my dependents are entitled under the terms of the
policy.
Print name
Group policy number
Signature of employee
X
Date
Signature of witness
X
Date
919310
919310
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2018 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
XGR/1641 LTD Claim Packet - Claimant Page 12 of 12 1/18
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Wellesley Hills, MA 02481
1-800-247-6875
PRIVACY INFORMATION NOTICE
This notice explains why Sun Life Assurance Company of Canada (“the Company”) collects personal information about you, how we
use that information, and under what circumstances we disclose it to others.
COLLECTION OF INFORMATION
We need to obtain information about you to determine whether we can provide the insurance benefits you have requested. As part of
the claims process, we may ask you to undergo a physical examination, submit a statement from your physician, or provide copies of
medical tests or other information relating to your health, finances and activities.
We also may collect information about you from other sources. By signing the Authorization For Release And Disclosure of Health
Related Information and/or the Authorization For Release And Disclosure of Psychotherapy Notes, you authorize us to obtain medical
information about you that we need to underwrite your application or to evaluate your claim. Depending upon your particular
circumstances, we may collect additional information about you from the following sources:
• Physicians, healthcare providers, medical professionals, hospitals, clinics or other medical or healthcare related facilities
• Other insurance companies you have applied to for insurance
• Public records, such as Social Security and tax records
DISCLOSURE OF PERSONAL INFORMATION
When you sign the Authorization For Release And Disclosure of Health Related Information and/or the Authorization For Release
And Disclosure of Psychotherapy Notes, you authorize us to disclose information we have about you:
• To our reinsurers
• As required or permitted by law
In the course of the claims process, we may need to disclose information about you to others. The law permits us to disclose
such information, without obtaining authorization from you, to:
• Companies that help us conduct our business or perform services on our behalf
• Your physician or treating medical professional
• Comply with federal, state or local laws, respond to a subpoena or comply with an inquiry by a government agency
or regulator
ACCESS, CORRECTION AND AMENDMENT OF PERSONAL INFORMATION
Upon written request to the Company, you can:
• Obtain a copy of the personal recorded information we have about you in our files (a fee may be charged to cover the cost of
providing a copy of such information)
• Request that we correct, amend or delete any recorded personal information about you in our possession
• File your own statement of facts if you believe that the recorded personal information we have about you is incorrect
To take any of these actions, please contact us at the following address for further instructions:
Sun Life Assurance Company of Canada
Group Long Term Disability Claims
P.O. Box 81830
Wellesley Hills, MA 02481
919310
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Sun Life Assurance Company of Canada (Cape Fear Community College)

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Completed 1 October 2020

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