Sun Life Assurance Company of Canada

Disability Claim Statement - Employee

Instructions
Please submit a disability claim if you have a disability that extends beyond the elimination period that’s included i n your
employer’s group policy.
Please complete, sign and date this form, including the medical authorizations, and return it to us along with the following
documents (as applicable):
 Reimbursement Agreement
 Direct Deposit Authorization
 Third Party Authorization

You may also submit this statement online at www.sunlife.com/us, click on Submit a Disability Claim. Please
send the additional documents by mail or fax:
Mail: Sun Life Assurance Company of Canada, Short-Term Disability Claims, P.O. Box 81915, Wellesley, MA 02481
Fax: 781-304-5599
If complete and accurate information is not provided, we may need to request additional information, which could
delay your disability benefits.
Group policy number
934397

1 | General information
Name of employee (first, middle initial, last) M Social Security number Date of birth (mm/dd/yyyy)
F
Email address*

Street Address City State Zip code

Occupation Home phone number Cell phone number Marital status

Spouse’s name (first, middle initial, last) Social Security number Date of birth (mm/dd/yyyy)

Can we leave you a detailed voicemail if we are unable to reach you by phone? .............................................. Yes No
Is your spouse employed? ............................................................................................................................................... Yes No

Names and dates of birth of your children (under age 25)

*By providing your e-mail address, you consent to electronic delivery of information and communications, including legally required
notices or disclosures, about your claim and all future claims with Sun Life. In order to receive electronic communications from us,
you must have access to a computer or mobile device with an Internet connection, a valid email account and software to access it.
You will be required to create a password and log in to the Sun Life Certified Mail portal in order to access the communications. A
communication posted to the portal will be considered to have been delivered to you when Sun Life sends an email message to your
email address on file with Sun Life informing you that the communication is available for review on the portal.
You may withdraw your consent, update your email address, or request a paper copy of any e lectronic document by contacting Sun
Life at 1-800-247-6875.
Even if you have provided your email address and consented to electronic delivery, Sun Life may at its option deliver communications
to you on paper and require that certain communications and other information from you be delivered to Sun Life on paper. If you
provide us with an invalid e-mail address, or if there is a subsequent malfunction of a previously valid e-mail address, Sun Life may
treat this as a withdrawal and termination of your consent to receive electronic communications.

GDIFM-8644 STD Disability Claim Statement – Employee (STD) 1 of 11 8/19

Claimant: DOB: Policy no.: 934397 CC no:
2 | Information about the condition causing your disability
Sun Life believes that work is healthy. We hope that we can be of assistance in getting you safely back to work.

Last day worked (before disability) Date first treated by Physician Date expected to return to work

Did you require Emergency Room care for your condition? .................................................................................... Yes No
If “Yes,” provide hospital name Date (mm/dd/yyyy) Hospital phone number

Were you confined to a hospital for this condition? ................................................................................................... Yes No

If “Yes,” provide hospital name Date(s) of confinement (mm/dd/yyyy) Hospital phone number
From: To:

Select the appropriate type of condition, and provide details:

Motor vehicle accident
Attached accident report with this statement
Pregnancy
Expected due date (mm/dd/yyyy) Actual delivery date (mm/dd/yyyy)
Delivery type Normal C-Section
Complications

Work-related injury/sickness
Date of first symptom/injury (mm/dd/yyyy) : Where occurred:
Cause of injury/sickness:
Do you intend to file for Workers’ Compensation? .................................................................................................... Yes No
If “Yes,” what is the status? Denied Approved Pending Appealed

Sickness
Date of first symptom (mm/dd/yyyy) Type of sickness

Have you experienced symptoms in the past?............................................................................................................ Yes No

If “Yes,” provide the date

3 | Other income information

If you receive other income, please provide us with any approval/denial letters.
Source of Income Weekly or monthly Payment Amount
Sick Pay Weekly Monthly $

Salary Continuance Weekly Monthly $

State Disability Weekly Monthly $

Workers’ Compensation Weekly Monthly $

Unemployment Weekly Monthly $

Social Security Disability Weekly Monthly $

Disability/Retirement Pension Weekly Monthly $

Other: Weekly Monthly $

GDIFM-8644 STD Disability Claim Statement – Employee (STD) 2 of 11 9/19

Claimant: DOB: Policy no.: 934397 CC no:
4 | Physician information
List physicians you are seeing or have seen for this condition.

Name of physician Specialty

Address

Phone number Fax number Date of last visit (mm/dd/yyyy) Date of next visit (mm/dd/yyyy)

Have you discussed a return to work plan with this physician? .............................................................................. Yes No

Name of physician

Address

Phone number Fax number Date of last visit (mm/dd/yyyy) Date of next visit (mm/dd/yyyy)

Have you discussed a return to work plan with this physician? .............................................................................. Yes No

If you need more room, check here and attach a separate sheet.

5 | Signature
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 Date signed (mm/dd/yyyy)

X

6 | Fraud warnings
General fraud 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, information 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 claim 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
benefit 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 fraudulent 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 ins urance company for
the purpose of defrauding 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 information 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.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 3 of 11 8/19
Claimant: DOB: Policy no.: 934397 CC no:
6 | Fraud warnings, continued
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 and 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.
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 benefit 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 an 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
containing 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 subject 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 guilt y 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: Any person who, with intent to defraud or knowingly providing false information may be guilty of fraud and may be
subject to civil or criminal penalties.
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 felony 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 aggravating 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.
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.
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.

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. Al l rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 4 of 5 8/19
Claimant: DOB: Policy no.: 934397 CC no:
Sun Life Assurance Company of Canada
|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 claimant or personal representative of claimant Group policy number

934397
If representative, description of your authority or relationship to claimant Claimant date of birth (mm/dd/yyyy)

Signature of claimant or personal representative Date signed (mm/dd/yyyy)

X

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. Al l rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 5 of 5 8/19
Claimant: DOB: Policy no.: 934397 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 c laims, 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 claimant or personal representative of claimant Group policy number
934397
If representative, description of your authority or relationship to claimant Claimant date of birth (mm/dd/yyyy)

Signature of claimant or personal representative Date signed (mm/dd/yyyy)

X

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. Al l rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 6 of 5 8/19
Claimant: DOB: Policy no.: 934397 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 claimant or personal representative of claimant Group policy number
934397
If representative, description of your authority or relationship to claimant Claimant date of birth (mm/dd/yyyy)

Signature of claimant or personal representative Date signed (mm/dd/yyyy)

X

Contact us
By mail By fax
Sun Life Assurance Company of Canada 781-304-5599
Group Short-Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481

www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 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 Lif e Assurance Company of Canada.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 7 of 5 8/19
Claimant: DOB: Policy no.: 934397 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 inform ation 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 Short-Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 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.
GDIFM-8644 STD Disability Claim Statement – Employee (STD) 8 of 11 8/19
Claimant: DOB: Policy no.:934397 CC no:
Sun Life Assurance Company of Canada
Reimbursement Agreement – Group Short-Term Disability

I UNDERSTAND and agree that the provisions of Group Short-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 Short-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 advance payment of the Short-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 amounts 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 advance to me t he
disability benefits to which I or my dependents are entitled under the terms of the policy.

Print name Group policy number

934397
Signature of employee Date (mm/dd/yyyy)
X
Signature of witness Date (mm/dd/yyyy)
X

Contact us

By mail By fax
Sun Life Assurance Company of Canada 781-304-5599
Group Short-Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481

www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 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.
GDIFM-8649 STD Reimbursement Agreement – STD Claims 5/19
Claimant: DOB: Policy no.: 934397 CC no:
Sun Life Assurance Company of Canada
Direct Deposit Authorization

To enjoy the safety and convenience of Sun Life Financial’s direct deposit services, simply complete this form and return it
to your Sun Life Financial representative.

Important: To verify your bank and financial information, attach a void check or a signed letter from your bank on their
letterhead. We cannot set up direct deposit services without this information.

1 | Insured information (please print clearly)

Name of insured/employee Policy number
934397
Street address

City State Zip code

Name of authorized representative signing this form (if applicable) Title Phone number

2 | Financial institution
Remember to attach a void check or signed letter from your bank on their letterhead to verify the bank or financial
institution information you provide below. We cannot set up direct deposit services without this information.
Name of bank or financial institution City and state of bank or financial institution

Insured/employee’s account number at bank or financial institution Bank or financial institution routing number

3 | Insured authorization statement

I hereby authorize Sun Life Assurance Company of Canada, including any of its subsidiaries and affiliates, to make all
payments due under the policy listed above by direct deposit to the account designated above. This authorization shall be
effective until further written notice from me, or another legally authorized representative, is received by Sun Life
Assurance Company of Canada.
To correct any overpayments credited to this account, I hereby authorize and direct the financial institute designated
above to debit this account and refund such overpayment to Sun Life Assurance Company of Canada.

Signature of insured/employee Date (mm/dd/yyyy)

X

Signature of authorized representative (if applicable) Date (mm/dd/yyyy)

X

Contact us

By mail By fax
Sun Life Assurance Company of Canada Short Term Disability Claims: 781-304-5599
One Sun Life Executive Park Long-Term Disability Claims: 781-304-5537
Wellesley Hills, MA 02481
By e-mail
[email protected]
www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET

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.
GGFM-3803 Direct Deposit Authorization 9/18
Claimant: DOB: Policy no.: 934397 CC no:
Sun Life Assurance Company of Canada
Third Party Authorization - Group Short-Term Disability Claims
You are not required to sign this optional authorization. However, to authorize Sun Life Assurance Company of Canada
and its affiliates (collectively “Sun Life”) to communicate with a family member, friend or other third party about your
Short-Term Disability claim, we need your consent.
To provide your consent, please complete, sign and date this authorization, then return it by mail, fax or e-mail using the
information provided in the “Contact us” section below.
Claim control number (“my claim”) Group STD policy number
934397

1 | Authorized person(s)
To assist in the evaluation or administration of my claim, I authorize Sun Life to share information about my claim with the
following “authorized person(s)”:
Name Relationship to employee Name Relationship to employee

2 | Signature(s)
If you are signing this form on behalf of the employee as a power of attorney, trustee, guardian, custodian, conservator, or
designee, please sign in your fiduciary capacity. We will also need your authorizing documents to communicate with you.
Please attach them to this form.
I/we acknowledge that I/we have read and agree to the following terms and conditions of this authorization.
 I/we authorize Sun Life to leave messages about my claim on my voice mailboxes and the voice mailboxes of the
authorized person(s) listed above.
 I/we understand that information about my claim may include information about my health, my claimed disability, my
work status, the terms of my coverage, and any potential benefits that may be available to me.
 I/we understand that this authorization is limited solely to sharing information related to my claim and that no third
party is authorized to make decisions on my behalf with respect to my claim.
 I/we understand that this authorization is valid for the duration of my claim. If a new claim is started, a new
Authorization form is needed for that claim. I further understand that I may withdraw this authorization at any time by
notifying Sun Life in writing that this authorization is withdrawn.
 I/we understand that my authorized representative and I are entitled to receive a copy of this authorization upon
request. I/we also understand that a copy of this authorization shall be valid as the original.
Employee name Date of birth (mm/dd/yyy)

Signature Date signed (mm/dd/yyyy)

X
Authorized representative name (if applicable) Relationship to employee

Signature Date signed (mm/dd/yyyy)

X

Contact us
By mail By fax By e-mail
Sun Life Assurance Company of Canada 781-304-5599 [email protected]
Group Short-Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481
www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 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.
GDIFM-8650 STD Third Party Authorization – STD Claims 5/19
Claimant: DOB: Policy no.: 934397 CC no: