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2023-2024 Benefits Guide
HOWTOENROLLYouwillbeabletocompleteyourenrollmentbyfollowingthestepslistedbelow. ENROLLMENTOPTIONS 01You canenrollindependently throughouronline EnrollmentPlatform. Logininstructionsareincludedon the nextpage.
_________________________________EMPLOYEE BENEFITS: HOWTO LOGINTOBERNIE PORTALACCOUNTBelow are the instructions for how to login both with and without an email address:How to login with email:Go to: https://www.bernieportal.com/en/loginEmployee default logins:Username: email addressPassword: Selecttheforgotpasswordoption ifyou donotrememberorhavenotsetoneupbefore.ORHow to login without email:https://www.bernieportal.com/en/emplovercode/loginEmployee code logins:2-digit code: 2-digit birth month (Example:March=03)4-digit code: last 4 of socialEmployer code:____________C-Side DecoratingqVV0tL
____________________________________________thrivesonbalance–balancingprofessionalandpersonalworlds–balancingworkandrest–whilealwaysbalancingcostandvalue.Wealsounderstandthatbalancemustbeindividualized.Whatisrightforonepersonmaynotbeappropriateforanother.Itisourgoaltoofferchoicesallowingyoutotailoryourbenefitsplanspecificallytowhatisbestforyouandyourfamilymembers.YourChoices___ Providesacompletepackageofbenefitsaimedatprovidingflexibleinsuranceprotectionandprogramstomeetyourever-changingneeds.___ sharesthecostofsomebenefitswithyou,whilemakingadditionalbenefitsavailablethatyoupayforifyouchoosetoenroll.Thepartofthebenefitcoststhatyouareresponsibleforwillbeautomaticallydeductedfromyourpaycheck,eitherbeforeorafteryourtaxesarecalculated.BenefitPre-TaxorPostTaxWhopaysthecost?WhydoIpayforsomebenefitswithbefore-taxmoney?Whilenotallbenefitsqualifyforpre-taxcontribution,thereisadefiniteadvantagetopayingforthosethatdo:Takingthemoneyoutbeforeyourtaxesarecalculatedlowerstheamountofyourtaxableincome.Therefore,youpaylessintaxes.HowYourBenefitsWorkFull-timeemployeesareeligibleformostbenefitson_____________________________________ofhire.MakingChangesGenerally,youcanonlychangeyourbenefitschoicesduringtheannualBenefitsEnrollmentPeriod.However,youcanchangeyourbenefitschoicesduringtheyearifyouhavealifeeventchange.Lifeeventchangesincludebutarenotlimitedto:·� Marriage·� Divorce·� Birth,adoption,orplacementforadoptionofaneligiblechild·� Deathofyourspouseorcoveredchild·� Changeinyouoryourspouse’sworkstatusthatresultsincancellationofyourbenefits·� BecomingeligibleforMedicareorMedicaidduringtheyearIfyouhavealifeeventchange,youmustnotifyHumanResourceswithin31daysofthechange(forexample,amarriageorbirthcertificate).Ifyoudo notnotifyHumanResourceswithin31days,youwillhavetowaituntilthenextannualOpenEnrollmentperiodtomakebenefitschangesunlessyouhaveanotherlifeeventchange.Anychangesyoumaketoyourbenefitchoicesmustbedirectlyrelatedtothelifeeventchange.C-Side DecoratingC-Side DecoratingC-Side Decoratingthe first day of the month following 30 daysC-Side DecoratingPre-Tax Employer SharedPre-Tax Employee PaidPost-Tax Employee PaidHealth InsuranceDental InsuranceLife Insurance
PortabilityIfyouleavethecompany,someofyourbenefitsendandsomeofyourbenefitsareportable.Thismeansyoucantakethemwithyouifyouleave,aslongasyoucontinuetopaythepremiumsyourself.Onceterminated,youwillbenotifiedthroughthemailifanyofyourbenefitsareportable.WhenCoverageEndsBenefitsendonthelastdayofthemonthfollowingterminationorwhenyouceasetomeeteligibilityguidelines.� � � � � � � �� Lookingahead……Nowlet’slookateachbenefitthatmakesupthebenefitsprogram.Inthefollowingpages,you’lllearnmoreaboutthevaluablebenefitsyouremployeroffers.You’llalsoseehowchoosingtherightcombinationofbenefitscanhelpprotectyouandyourfamily’shealth.NOTES:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Continuing Your CoverageUndercertaincircumstances,youmay continue yourhealthcarecoveragewhenitwouldotherwiseend.ThisiscalledCobraappliestotheseplans:· HealthInsurance· DentalInsurance· VisionInsuranceWhencan I continue coverage under____________________?Youand/oryourdependentsareeligibletocontinuehealthcarecoverageunder________________________If coverageislostbecause:· Your employment endsforanyreasonother than“grossmisconduct”.· Yourworkhours are significantlyreduced.· Youdie.· Youbecome entitled toandenrollinMedicarepriortolosingcoverage.· Youdivorceorbecomelegallyseparatedfromyourspouse.· Yourdependentlosesdependentstatus.________________State ContinuationState ContinuationState ContinuationC-Side Decorating
G664ADT P611ADTHMO HMOIn InDeductible$2,000 $1,250Family Deductible$6,000 $3,750Coinsurance80% 100%Out-Of-Pocket$6,000 ($17,100) $1,250 ($3,750)Office Visit$30 Copay $25 CopaySpecialty Doctor Office Visit$60 Copay $45 CopayInpatient Hospital Services$150 Copay + 80% After Ded. $150 Copay + 80% After Ded.Preventative Lab & X-Ray80% After Ded. 100% After Ded.Advanced Imagining$250 Copay $250 CopayUrgent Care$75 Copay $25 CopayEmergency Room$300 Copay + 80% After Ded. $400 Copay + 100% After Ded.RX0/10/50/100/150/250 0/10/35/75/150/250PCPYes YesEmployees Weekly Rate Employees Weekly RateEmployee Only $64.78 $77.38Employee + Spouse $194.34 $232.13Employee + Child(ren) $194.34 $232.13Employee + Family $323.90 $386.88$445.88NoEmployees Weekly Rate$89.18$267.53$267.53$350 Copay + 90% After Ded.$100 Copay + 90% After Ded.$150 Copay$75 Copay$400 Copay + 90% After Ded.0/10/50/100/150/250$8,500 ($17,000)$30 Copay$60 CopayIn$3,000$9,00090%G9L7CHCPPO
C-Side Decorating, Inc.All Employees
Sun Life Assurance Company of Canada800-247-6875 • sunlife.com/us2189870 VLIF DEN 05/03/2023 09:34:36BENEFITS AT A GLANCE:´ Dental insurance to help maintain healthy smiles and betteroverall health, too.´ Voluntary Life insurance to protect your family if somethinghappens to you.If you’re reading this, it must be enrollment time. But don’tsweat it, because we’ve got you covered. We’ll provide youwith the right information to get the coverage that’s best foryou and your family. Some of our offerings might be new toyou. Take some time to read through this booklet, so that youfeel confident about your choices. And keep in mind that anybenefits you choose are easily paid for through payrolldeduction.Find your benefits here.C-SIDE DECORATING, INC.POLICY #: 960650
Sun Life Assurance Company of Canada2189870 DEN13 CL1 05/03/2023 09:33:59800-247-6875 • sunlife.com/us Dental Insurance PROTECTS YOUR SMILE.You can feel more confident with dental insurance thatencourages routine cleanings and checkups. Dentalinsurance helps protect your teeth for a lifetime. PREVENTS OTHER HEALTH ISSUES.Just annual preventive care alone can help prevent otherhealth issues such as heart disease and diabetes. Manyplans cover preventive services at or near 100% to make iteasy for you to use your dental benefits. LOWERS OUT-OF-POCKET EXPENSES.Seeing an in-network dentist can reduce your feesapproximately 30% from their standard fees. Add thebenefits of your coinsurance to that and things are lookinggood for your wallet.DentalInsuranceDENTAL FAST FACTSTreating the inflammationfrom periodontal diseasecan help manage otherhealth problems such asheart disease anddiabetes.150% of adults over the ageof 30 are suffering fromperiodontal disease.2COMMONLYCOVEREDExams and cleaningsX-raysFillingsTooth extractionsRoot canals
800-247-6875 • sunlife.com/us Dental InsuranceWhat’s coveredGood news!Your plan covers routine serviceslike cleanings and exams at 100%.CALENDAR YEAR MAXIMUMIN-NETWORK OUT-OF-NETWORKType I, II, III (Preventive, Basic and Major Services) $1,500 per person $1,500 per personSERVICESType I Preventive Dental Services, including:• Oral evaluations – 1 in any 6 month period• Routine dental cleanings – 1 in any 6 month period• Fluoride treatment – 1 in any 6 month period. Only forchildren under age 14• Sealants – no more than 1 per tooth in any 36 monthperiod, only for permanent molar teeth. Only forchildren under age 14• Space maintainers – only for children under age 19• Bitewing x-rays – 1 in any 12 month period• Intraoral complete series x-rays – 1 in any 60 monthperiod• Genetic test for susceptibility to oral diseasesType II Basic Dental Services, including:• New fillings• Simple extractions, incision and drainage• Minor gum disease (non-surgical periodontics)• Scaling and root planing – 1 in any 24 month periodper area• Periodontal maintenance – 1 in any 6 consecutivemonths• Localized delivery of antimicrobial agents• Stainless steel crowns – only for children under age 19• Major gum disease (surgical periodontics)Type III Major Dental Services, including:• Dentures and bridges – subject to 10 year replacementlimit• Inlay, onlay, and crown restorations – 1 per tooth inany 10 year period• Surgical extractions of erupted teeth, impacted teeth,or exposed root• Biopsy (including brush biopsy)• Endodontics (includes root canal therapy) – 1 per toothin any 24 month period• Complex oral surgery• General anesthesia/IV sedation – medically requiredWaiting PeriodsFor a complete description of services and waiting periods,please review your certificate of insurance. If you werecovered under your employer’s prior plan the wait will bewaived for any type of service covered under the prior planand this plan.• No waiting period for preventive, basic or majorservicesTHE PLAN PAYS THE FOLLOWING PERCENTAGE FOR PROCEDURESPROCEDUREIN-NETWORK OUT-OF-NETWORKType I Preventive Services 100% 100%Type II Basic Services 80% 80%Type III Major Services 50% 50%CALENDAR YEAR DEDUCTIBLEPROCEDUREIN-NETWORK OUT-OF-NETWORKType I Preventive Services N/A N/AType II, III (Basic and Major Services) $50 individual/$150 family $50 individual/$150 family
800-247-6875 • sunlife.com/us Dental InsuranceFrequently asked questionsHow does a PPO work?PPO stands for Participating Provider Organization. With adental PPO plan, dental providers agree to participate in adental network by offering discounted fees on mostdental procedures. When you visit a provider in thenetwork, you could see lower out-of-pocket costsbecause providers in the network agree to these pre-negotiated discounted fees on eligible claims.How do I find a dentist?Simply visit www.sunlife.com/findadentist. Follow theprompts to find a dentist in your area who participates inthe PPO network. You do not need to select a dentist inadvance. The PPO network for your plan is the Sun LifeDental Network® with 130,000+ unique dentists3.Do I have to choose a dentist in the PPO network?No. You can visit any licensed dentist for services.However, you could see lower out-of-pockets costs whenyou visit a dentist in the network.Are my dependents eligible for coverage?Yes. Your plan offers coverage for your spouse4anddependent children. An eligible child is defined as a childto age 26.5What if I have already started dental work, like a rootcanal or braces, that requires several visits?Your coverage with us may handle these proceduresdifferently than your prior plan. To ensure a smoothtransition for work in progress, call our dental claimsexperts before your next visit at 800-442-7742.Do I have to file the claim?Many dentists will file claims for you. If a dentist will notfile your claim, simply ask your dentist to complete astandard American Dental Association (ADA) claim formand mail it to:Sun LifeP.O. Box 2940Clinton, IA 52733How can I get more information about my coverageor find my dental ID card?After the effective date of your coverage, you can viewbenefit information online at your convenience throughyour Sun Life account. To create an account go towww.sunlife.com/account and register. You can alsoaccess this information from our mobile app—BenefitTools, which is available for Apple and Android devices. Oryou can call Sun Life’s Dental Customer Service at 800-442-7742. You can also call any time, day or night, toaccess our automated system and get answers tocommon questions when it’s convenient for you.What value added benefits does my plan include?Your plan includes our Lifetime of Smiles® program,with benefits many people prefer, such as brush biopsiesfor the early detection of oral cancer.CONSIDER APRE-DETERMINATIONOF BENEFITSThey allow us to review yourprovider’s treatment plan to letyou know before treatment isstarted how much of the workshould be covered by the plan,and how much you may need tocover. We recommend them forany dental treatment expectedto exceed $500.1. American Academy of Periodontology https://www.perio.org/consumer/gum-disease-and-other-diseases (accessed 07/21).2. American Academy of Periodontology https://www.perio.org/newsroom/periodontal-disease-fact-sheet (accessed 07/21).3. Zelis Network Analytics data as of January 2022 and based on unique dentist count. Sun Life's dental networks include its affiliate, DentalHealth Alliance, L.L.C.® (DHA), and dentists under access arrangements with other dental networks. Nationwide counts are state level totals.4. If permitted by the Employer’s employee benefit plan and not prohibited by state law, the term “spouse” in this benefit includes anyindividual who is either recognized as a spouse, a registered domestic partner, or a partner in a civil union, or otherwise accorded the samerights as a spouse.5. Please see your employer for more specific information.Read the Important information section for more details including limitations and exclusions
800-247-6875 • sunlife.com/us Dental InsuranceDental plan provisionsBenefit adjustmentsBenefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits willbe payable for the most economical services or supplies meeting broadly accepted standards of dental care.Late entrantIf you or a dependent apply for dental insurance more than 31 days after you become eligible, you or your dependentare a late entrant. The benefits for the first 12 months for late entrants will be limited as follows:TIME INSURED CONTINUOUSLY UNDER THE POLICY BENEFITS PROVIDED FOR ONLY THESE SERVICESLess than 12 months Preventive and Basic ServicesAt least 12 months Preventive, Basic and Major ServicesWe will not pay for treatments subject to the late entrant limitation, and started or completed during the late entrantlimitation period.
Coverage and monthly cost for Dental.Rates are effective as of June 1, 2023.Dental coverage is contributory. You are responsible for paying for all or a part of the cost through payroll deduction.Coverage Cost per pay period*Employee $26.01Employee + Spouse $52.02Employee + Child(ren) $58.78Employee + Family $84.79*Contact your employer to confirm your part of the cost.Dental InsuranceRates800-247-6875·sunlife.com/us
BENEFITS (You can purchase this coverage at a group rate.)For you*You can choose from $25,000 to $100,000—inincrements of $25,000 not to exceed 5 times your BasicAnnual Earnings. No medical questions asked up to theGuaranteed Issue amount of $25,000.Benefits are reduced at age 65 and may reduce again insubsequent years as noted in your Certificate.For yourspouse*If you elect coverage for yourself, you can choose from$12,500 to $25,000—in increments of $12,500. Nomedical questions asked up to the Guaranteed Issueamount of $12,500.The amount you select for your spouse cannot exceed50% of your coverage amount. Coverage ends when youturn age 70.For yourchild(ren)*If you elect coverage for yourself, you can choose $2,500to $10,000—in $2,500 increments. No medical questionsasked.The amount you select for your child(ren) cannot exceed50% of your coverage amount. Benefits may reduce asnoted in your Certificate. Child(ren) must primarilydepend on the employee for 50% or more of theirsupport.A full benefit is payable for a dependent child who is 6months to 25. A reduced benefit of $500 is payable for achild from 14 days to 6 months. (No benefit is payable fora child from birth to 14 days).*This coverage includes Accidental Death and Dismemberment insurance.MORE PROTECTIONFOR YOUR LOVED ONES.The people you love andsupport could face financialchallenges without you.Life insurance provides yourloved ones with money theycan use for householdexpenses, tuition, mortgagepayments and more.HELPS YOU CLOSE ANYCOVERAGE GAPS.You may have lifeinsurance today, eitheron your own or through youremployer. Now is a goodtime to ask yourselfif you need more coverage.800-247-6875 • sunlife.com/us Voluntary Life InsuranceSun Life Assurance Company of Canada2189870 SEQ11 CL1 05/03/2023 09:33:57Voluntary LifeInsurance
Voluntary Life Insurance800-247-6875 • sunlife.com/us1. LIMRA, Facts about Life 2018.Read the Important information section for more details includinglimitations and exclusions.What is my AD&D benefit?We will pay your beneficiaries an Accidental Death insurance amount that matches your VoluntaryLife, if you die from a covered accident. Additional benefits are available for accidental injuries (i.e.,dismemberment) such as loss of limbs, fingers or sight. Refer to your Certificate for a full list ofcovered accidental injuries. This plan includes AD&D coverage for your dependents.Do I need to answer any health questions to enroll?Yes, if you request an amount higher than the Guaranteed Issue amount. You may need tocomplete health questions if you don’t elect coverage when it’s first available to you and you wantto elect at a later date, or if you want to increase coverage. To answer health questions, please fillout our Evidence of Insurability application. Health questions must be approved by Sun Life beforecoverage takes effect. Please see your Certificate for details.Can I take my insurance with me if I leave my employer?Depending upon state variations and your employer’s plan, you may have an option to continuegroup coverage when your employment terminates. Your employer can advise you about youroptions.Can I access my life insurance if I become terminally ill?You may apply to receive a portion of your life insurance to help cover medical and livingexpenses. This is called an “Accelerated Benefit” and there are some important things to knowabout it, including that it is not long-term-care insurance, it may be taxable and it may affect youreligibility for public assistance programs. It will also reduce the total amount of the life insurancepayment we pay to your beneficiary(ies).What happens if I become Totally Disabled?If we determine that you are Totally Disabled and cannot work, your life insurance coverage maycontinue at no cost. You must meet certain requirements, as detailed in the Certificate.How does my beneficiary file a death claim?Your beneficiary(ies) and your employer will complete the appropriate claims forms and submitthem to us. We will notify your beneficiaries when the decision is made and if we have anyquestions. If approved, beneficiaries may elect to receive a lump sum payment or to have thebenefit paid into an account where the funds accumulate interest and can be withdrawn at anytime. (State restrictions apply and options may vary by state.) If your AD&D claim for an accidentalinjury is approved, the benefit amount will be paid directly to you.Frequently asked questions
Employee - Coverage and monthly cost for Employee Voluntary Life and AD&D.Rates are effective as of June 1, 2023.The chart below shows possible coverage amounts and their monthly costs.Find your age bracket (as of the effective date of coverage) to see the cost for the coverage amount you choose.CoverageAge and costamounts <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+$25,000 2.05 2.05 2.05 2.45 3.25 4.90 6.85 10.53 15.83 23.40 46.43 99.90 198.83 393.13$50,000 4.10 4.10 4.10 4.90 6.50 9.80 13.70 21.05 31.65 46.80 92.85 199.80 397.65 786.25$75,000 6.15 6.15 6.15 7.35 9.75 14.70 20.55 31.58 47.48 70.20 139.28 299.70 596.48 1179.38$100,000 8.20 8.20 8.20 9.80 13.00 19.60 27.40 42.10 63.30 93.60 185.70 399.60 795.30 1572.50Voluntary Life InsuranceRates800-247-6875·sunlife.com/us
Spouse - Coverage and monthly cost for Spouse Voluntary Life and AD&D.Rates are effective as of June 1, 2023.The chart below shows possible coverage amounts and their monthly costs.Find your spouse's age bracket (as of the effective date of coverage) to see the cost for the coverage amount you choose.Spouse rates are based on the spouse's age.CoverageAge and costamounts <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69$12,500 2.11 2.11 2.11 2.60 3.58 5.60 7.99 12.44 18.91 28.20$25,000 4.23 4.23 4.23 5.20 7.15 11.20 15.98 24.88 37.83 56.40Child - Coverage and monthly cost for Child Voluntary Life and AD&D.Rates are effective as of June 1, 2023.The chart below shows possible coverage amounts and their monthly costs.Coverage amounts Cost per pay period$2,500 0.66$5,000 1.31$7,500 1.97$10,000 2.62Voluntary Life InsuranceRates800-247-6875·sunlife.com/us
800-247-6875 • sunlife.com/usSun Life Assurance Company of CanadaImportant informationThe following coverage(s) do not constitute comprehensive health insurance (often referred to as “majormedical coverage”). They do NOT provide basic hospital, basic medical, or major medical insurance.To become insured, you must meet the eligibility requirements set forth by your employer. Your coverage effective datewill be determined by the Policy and may be delayed if you are not actively at work on the date your coverage wouldotherwise go into effect. Similarly, dependent coverage, if offered, may be delayed if your dependents are in the hospital(except for newborns) on the date coverage would otherwise become effective. Refer to the Certificate for details.Limitations and exclusionsThe below exclusions and limitations may vary by state law and regulations. This list may not be comprehensive. Pleasesee the Certificate or ask your benefits administrator for details.DentalWe will not pay a benefit for any Dental procedure, which is not listed as a covered dental expense. Any dental serviceincurred prior to the Effective date or after the termination date is not covered, unless specifically listed in thecertificate. A member must be a covered dental member under the Plan to receive dental benefits. The Plan hasfrequency limitations on certain preventive and diagnostic services, restorations (fillings), periodontal services,endodontic services, and replacement of dentures, bridges and crowns. All services must be necessary and providedaccording to acceptable dental treatment standards. Treatment performed outside the United States is not covered,except for emergency dental treatment, subject to a maximum benefit. Dental procedures for Orthodontics; TMJ;replacing a tooth missing prior the effective date; implants and implant related services; or occlusal guards for bruxismare not covered unless coverage is elected or mandated by the state.This plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimumessential coverage” as defined by The Patient Protection and Affordable Care Act (PPACA).LifeIn some states, your employer’s group policy may exclude payment for suicide that occurs within a specific time periodafter the insurance or increase in insurance becomes effective. Please see your Certificate for details.Accidental Death and DismembermentWe will not pay a benefit that is due to or results from: suicide while sane or insane; injuring oneself intentionally;committing or attempting to commit an assault, felony or other criminal act; war or an act of war; active participation ina riot, rebellion or insurrection; voluntary use of any controlled substance/illegal drugs; operation of a motorized vehiclewhile intoxicated; bodily or mental infirmity or disease or infection unless due to an accidental injury; riding in or drivingany motor-driven vehicle in a race, stunt show, or speed test.This Overview is preliminary to the issuance of the Policy. Refer to your Certificate for details. Receipt of this Overviewdoes not constitute approval of coverage under the Policy. In the event of a discrepancy between this Overview, theCertificate and the Policy, the terms of the Policy will govern. Product offerings may not be available in all states andmay vary depending on state laws and regulations.Sun Life companies include Sun Life and Health Insurance Company (U.S.) and Sun Life Assurance Company of Canada(collectively, “Sun Life”).Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states,except New York, under Policy Form Series 93P-LH, 98P-ADD, 12-GP-01, 15-GP-01, 15-LF-C-01, 15-ADD-C-01, 16-DEN-C-01, 16-VIS-C-01, 12-DI-C-01, 16-DI-C-01, 12-AC-C-01, 16-AC-C-01, 13-SD-C-01, 16-SD-C-01, 16-CAN-C-01, 20-HI-C-01, 12-GPPort-P-01, 20-HIPORT-C-01, TDBPOLICY-2006, and TDI-POLICY.© 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globesymbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us.GVBH-EE-8384 SLPC 295792189870 VLIF DEN 05/03/2023 09:34:35
Sun LifeOne Sun Life Executive Park, Wellesley Hills, MA 02481Group Enrollment FormSun Life Assurance Company of CanadaOne Sun Life Executive ParkWellesley Hills, MA 02481Employer use (check one): New employee Change COBRA1. General InformationEmployer NameC-Side Decorating, Inc.Account / Policy Number960650Location2. Employee InformationEmployee's Full Legal Name (First, M.I., Last)MaleFemaleDate of BirthStreet Address City State Zip CodeOccupation Eligibility Class(if applicable)Social Security Number Phone NumberDate employed: Full-Time Date: Return from layoff Date:Part-Time Date: RehireCurrent Active Employment Type# of hoursFull-Time Part-TimeEarnings$Hourly Weekly Monthly Annually Other:3. Dependent InformationPlease complete this entire section if you are selecting dependent coverage. No employee can be insured as a dependentwhen he/she is also insured as an employee for any benefit under the same policy.If more space is needed, please add additional pages.Relationship Full legal name(First, M.I., Last) GenderSocial SecuritynumberDate of birth StudentY / NSpouseChildrenGVMPEM-5627 (Rev 4/20)
4. Benefit ElectionsYou need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it. This mustbe done either during the enrollment period or within 31 days of your eligibility date. Benefits completely paid by your employer("non-contributory benefits") cannot be refused. Not all of the benefit options listed below will be necessarily available to you. Youremployer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is.Elect Refuse CoverageDental:Employee Employee + SpouseEmployee + Child(ren) Employee + FamilyWere you covered under another dental plan within the last 31 days? ....... .. .. .. ... ... . Yes NoIf "Yes," provide the termination date:Reason for termination of coverage?Employee Voluntary Life and Accidental Death & Dismemberment (AD&D) $Spouse Voluntary Life and Accidental Death & Dismemberment (AD&D) $Child(ren) Voluntary Life and Accidental Death & Dismemberment (AD&D) $5. Beneficiary Designation InformationPrimary Beneficiary DesignationOn the lines below, list the individual(s) who should receive proceeds in the event of your death. You may specify as manyindividuals as you like, but the total proceeds must equal 100%. This is your primary beneficiary. Attach additional pages ifnecessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death, proceeds will be payablein accordance with your Group insurance policy. Designation applies to all coverages for which a beneficiary designation isrequired.Primary Beneficiary(ies) Percent shareof proceeds*1 Name (First, M.I., Last) Relationship to employee Social Security number %Address Phone number Date of birth2 Name (First, M.I., Last) Relationship to employee Social Security number %Address Phone number Date of birth*Must equal 100%GVMPEM-5627 (Rev 4/20)
Secondary Beneficiary DesignationOn the lines below, list the individual(s) who should receive the proceeds ONLY IF ALL of the individuals listed above arenot living at the time of your death. This is your secondary (or contingent) beneficiary. The Secondary beneficiary is notpaid if a primary beneficiary is alive at the time of your death. Attach additional pages if necessary.Secondary Beneficiary(ies) Percent shareof proceeds*1 Name (First, M.I., Last) Relationship to employee Social Security number %Address Phone number Date of birth2 Name (First, M.I., Last) Relationship to employee Social Security number %Address Phone number Date of birth*Must equal 100%6. Signature and authorization informationI understand that:I am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when myemployment terminates, subject to any portability or continuation provisions available under the Group Insurancepolicy.My employer will deduct all or part of the premium for contributory coverage from my pay.If applying for coverage more than 31 days past my eligibility date, Evidence of Insurability may be required.For Life insurance, Evidence of Insurability may be required for amounts over my Guarantee Issue for thisenrollment.Increases to current Life benefits may require Evidence of Insurability.If I decline coverage for myself or, if applicable, for my family now and want it at a later date, I/we will have tosubmit an Evidence of Insurability application, if required for the elected coverage(s), to be approved by Sun LifeAssurance Company of Canada (Wellesley, MA). For Dental coverage, I understand that I will not be entitled tobenefits until the expiration of any Late Entrant benefit waiting period specified in the certificate of insurance.For Dental Insurance plans, I have the right to select any dental care provider of my choice.The dental plan includes a pre-determination provision that will advise me in advance of the benefits I may beeligible for if the procedure is performed.Coverages include benefit waiting periods, limitations and exclusions that may affect my entitlement to benefits.If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increasedcoverage is scheduled to start under the plan, such coverage will not start until the date I return to work.When required by the coverage, if my spouse or any of my dependent children are confined due to an injury orillness, as required by the coverage, on the date that any initial or increased coverage is scheduled to start under theplan, such coverage will not start until the date they are no longer confined and are able to perform their normalactivities.By signing below, I am representing that the information I have provided is true and correct to the best of my knowledgeand belief.XEmployee Signature Today's DateTo the Employee: Make a copy of this form for your records before submitting it to your employer.To the Employer: This original enrollment form should remain at the employer's site. Family status, coverage, orbeneficiary changes should be recorded on another copy of the Enrollment Form.GVMPEM-5627 (Rev 4/20)
Agent, Broker, and/or Enroller information:Agent nameAgent / Broker nameEnroller nameContact usBy mailSun LifeOne Sun Life Executive ParkWellesley Hills, MA 02481www.sunlife.com/us Customer Service 800-247-6875 M-F 8:00 a.m.-8:00 p.m., ETGVMPEM-5627 (Rev 4/20)