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[ Logo ] SUN LIFE ASSURANCE COMPANY OF CANADA (U.S.) [ PRODUCT NAME ]
Retirement Products and Services [1-8##-###-####]
P.O. Box [###] Boston, MA [#####] OR
One Copley Place Boston, MA 02116
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___________________________________________________________________________________________________________________________________
A PARTICIPANT/ Name * ________________________________________________________________________________________________________
OWNER Address________________________________________________________________________________________________________
City_________________________________________________________ State ________________________ Zip ______________
Date of Birth ____/_____/________ Social Security Number ___-__-_______________________ Gender / / M / / F
* IF A TRUST IS DESIGNATED AS PARTICIPANT/OWNER, A VERIFICATION OF TRUST FORM OR TRUST DOCUMENTS MUST ACCOMPANY
THIS APPLICATION.
___________________________________________________________________________________________________________________________________
B ANNUITANT / / Same as above, or Name:____________________________________________________________________________________
Date of Birth ____/_____/________ Social Security Number ___-__-_______________________ Gender / / M / / F
CO-ANNUITANT Name __________________________________________________________________________________________________________
(OPTIONAL) Date of Birth ____/_____/________ Social Security Number ___-__-_______________________ Gender / / M / / F
___________________________________________________________________________________________________________________________________
C PLAN / / Non-Qualified / / CRT (CRT WAIVER MUST ACCOMPANY THIS APPLICATION)
SELECTION / / IRA / / IRA Transfer / / IRA Rollover
/ / Roth IRA / / Roth IRA Rollover/Transfer
/ / 403(b) Full / / 403(b) Partial Transfer (BY CHECKING THIS BOX, PARTICIPANT/OWNER CERTIFIES THAT
Rollover/Transfer THE FUNDS TRANSFERRED CONTINUE TO BE SUBJECT TO THE SAME OR MORE STRINGENT
DISTRIBUTION RESTRICTIONS AS PRIOR TO THE TRANSFER.)
/ / Qualified Plan - TYPE ______________________________________ TRUSTEE _____________________________________
___________________________________________________________________________________________________________________________________
D BENEFICIARY Name Relationship to Participant/Owner Social Security Number
INFORMATION /X/ Primary __________________ ________________________________________ _____-_____-__________
/ / Primary / / Contingent __________________ ________________________________________ _____-_____-__________
/ / Primary / / Contingent __________________ ________________________________________ _____-_____-__________
/ / Please check here if you are attaching additional Beneficiary information
BENEFICIARY DESIGNATIONS MUST BE CONSISTENT WITH YOUR APPLICABLE RETIREMENT PLAN. FOR NON-QUALIFIED
CONTRACTS, THE CONTRACT/CERTIFICATE MAY BE CONTINUED AFTER THE DEATH OF THE PARTICIPANT/OWNER IF THE
PARTICIPANT/OWNER'S SPOUSE IS THE BENEFICIARY; OTHERWISE, THE DEATH BENEFIT MUST BE DISTRIBUTED. UNLESS
SPECIFIED OTHERWISE, THE DEATH BENEFIT WILL BE DIVIDED EQUALLY AMONG ALL PRIMARY BENEFICIARIES WHO SURVIVE
THE PARTICIPANT/OWNER. IF NO PRIMARY BENEFICIARY SURVIVES THE PARTICIPANT/OWNER, THE DEATH BENEFIT WILL BE
DIVIDED EQUALLY AMONG ANY CONTINGENT BENEFICIARIES WHO SURVIVE THE PARTICIPANT/OWNER.
___________________________________________________________________________________________________________________________________
E OPTIONAL DEATH
BENEFIT RIDERS (subject to state availability and age restrictions)
Optional death benefit riders may ONLY be chosen at time of application. Optional riders are offered as an
enhancement to the basic Death Benefit described in the prospectus. If an optional rider is not elected,
the basic Death Benefit will be paid to the beneficiary upon the death of a Participant/Owner. Optional
Death Benefit riders cannot be chosen if an Participant/Owner is age 80 or over at the time of application.
Once elected this option may not be changed.
/ / Maximum Anniversary Value Rider
/ / Earnings Enhancement Rider
/ / 5% Premium Roll-up Rider
___________________________________________________________________________________________________________________________________
F SPECIAL (Transfer Company Information; Additional Beneficiaries; Annuity Commencement Date; Annuity Option
INSTRUCTIONS election, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
G REPLACEMENT Will this Contract/Certificate replace or change any existing life insurance or annuity in this or any
other company? / / Yes / / No
If yes, please explain in Section F, SPECIAL INSTRUCTIONS and request replacement information from your
Registered Representative.
___________________________________________________________________________________________________________________________________
H PURCHASE Please indicate how you would like your Purchase Payment allocated and use whole percentages. Your
PAYMENT allocations should total 100%. This allocation will be used for future investments, unless otherwise
ALLOCATION specified.
INITIAL PURCHASE PAYMENT $__________________________ Minimum initial purchase payment $10,000.
Make check payable to SUN LIFE OF CANADA (U.S.). (Please estimate dollar amount for 1035 exchanges,
transfers, rollovers, etc.)
SUB-ACCOUNTS
[ P _______% _______%
R _______% _______%
O _______% _______%
D _______% _______%
U _______% _______%
C _______% _______%
T _______% _______%
___________________________________________________________________________________________________________________________________
PLEASE COMPLETE REVERSE SIDE
___________________________________________________________________________________________________________________________________
_______% _______%
_______% _______%]
_______% APPLY 60-DAY RATE HOLD
RCH-APP-00-1
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[ Logo ] SUN LIFE ASSURANCE COMPANY OF CANADA (U.S.) [ PRODUCT NAME ]
Retirement Products and Services [1-8##-###-####]
P.O. Box [###] Boston, MA [#####] OR
One Copley Place Boston, MA 02116
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_______% / / Yes / / No
N _______% ESTIMATED DOLLAR AMOUNT
A _______% $____________________________________
M _______% NOTE: A RATE HOLD IS IRREVOCABLE AND
E ] _______% IS ONLY AVAILABLE FOR 1035 EXCHANGES
AND DIRECT TRUSTEE-TO-TRUSTEE
TRANSFERS.
___________________________________________________________________________________________________________________________________
I ACCEPTANCE I hereby represent that my answers to the questions on this Application are correct and true to the best of
my knowledge and belief. ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT/CERTIFICATE WHEN BASED ON THE
INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. PAYMENTS
AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF
WHICH MAY RESULT IN UPWARD AND DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE. I have read the applicable fraud
warning for my state listed below. I acknowledge receipt of current product and fund prospectuses.
_______________________________________________________ ________________________________________________
Signature of Participant/Owner Date
_____________________________________________________________________ _________________________________
SIGNED AT City State
___________________________________________________________________________________________________________________________________
J REGISTERED Will this Contract/Certificate replace or change any existing life insurance or annuity in this or any other
REPRESENTATIVE company? / / Yes / / No
If YES, please explain in Section F, SPECIAL INSTRUCTIONS and complete replacement forms where applicable.
Signature of Registered Print name of Registered Representative
Representative ______________________ ___________________
Broker/Dealer ______________________ Branch Office Address ___________________
Telephone ______________________ City _________________ State___ Zip____________
/ / Option A / / Option B / / Option C Broker/Dealer Account # ______________________
___________________________________________________________________________________________________________________________________
FRAUD WARNINGS
For applicants in: ARKANSAS, KENTUCKY, MAINE, NEW MEXICO, OHIO AND PENNSYLVANIA:
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.
For applicants in NEW JERSEY:
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY
IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
For applicants in the DISTRICT OF COLUMBIA
"WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR PURPOSES OF
DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IT ADDITION,
AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED
BY THE APPLICANT."
For applicants in COLORADO:
IT IN UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE 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
POLICY HOLDER 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.
1 For applicants in FLORIDA:
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.
AGENT'S FLORIDA LICENSE ID NUMBER:____________________________________________________________________
RCH-APP-00-1
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