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[ Logo ] Sun Life Assurance Company of Canada (U.S.) [ PRODUCT NAME ]
Retirement Products and Services [1-8##-###-####] GROUP/OWNER APPLICATION
P.O. Box [### ] Boston, MA [#####] OR
One Copley Place Boston, MA 02116
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RCH-G/O-00-1
____________________________________________________________________________________________________________________________________
A GROUP/OWNER Name __________________________________________________________________________________________________________
INFORMATION Address _______________________________________________________________________________________________________
City _______________________________________________ State ________________________ Zip _____________________
Tax Identification Number _______-__________________
____________________________________________________________________________________________________________________________________
B TRUSTEES Ownership: Trustee(s) specified will be the Owner(s) of the Contract.
(IF APPLICABLE)
____________________________________________________________________________________________________________________________________
C MAILING Unless the box below is checked, confirmation statements will be mailed to the Address in Section A.
INSTRUCTIONS / / Mail statements directly to the Participant
____________________________________________________________________________________________________________________________________
D PLAN Qualified Plan type __________________________________________________________________________________________
SELECTION
____________________________________________________________________________________________________________________________________
E SPECIAL And Transfer of Assets information (IF APPLICABLE)
INSTRUCTIONS _______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
F REPLACEMENT Will this Contract/Certificate replace or change any existing life insurance or annuity in this or
CONTRACT any other company? / / Yes / / No
If YES, please explain in Section E, SPECIAL INSTRUCTIONS and request replacement information from your
Registered Representative.
____________________________________________________________________________________________________________________________________
G 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 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 on the
next page. I acknowledge receipt of current product and fund prospectuses.
_______________________________________________ ____________________________________________________
Authorized Signature (Group/Owner) Trustee Signature (if applicable)
_______________________________________________ _________________________ _________________________
SIGNED AT City State Date
____________________________________________________________________________________________________________________________________
H 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 E, SPECIAL INSTRUCTIONS and complete replacement forms where applicable.
_______________________________________________ ____________________________________________________
Signature of Registered Representative Print name of Registered Representative
_______________________________________________ ____________________________________________________
Branch Office Address Home Office Address
_________________ __________________ __________ _________________ _______________________ __________
City State Zip City State Zip
_________________ _____________________________ _________________ __________________________________
Telephone Fax Telephone Fax
____________________________________________________________________________________________________________________________________
I FRAUD For applicants in: ARKANSAS, KENTUCKY, MAINE, NEW MEXICO, OHIO AND PENNSYLVANIA:
WARNINGS 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 the DISTRICT OF COLUMBIA
"WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR PURPOSE OF DEFRAUDING
THE INSURER 0OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY
DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT."
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 COLORADO:
[ PRODUCT IT IN UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE
NAME ] 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.
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:____________________________________________________
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