Group Enrollmentform

SunLifeAssuranceCompanyof CanadaSunLifeandHealthInsuranceCompany(U.S.) OneSunLifeExecutivePark OneSunLifeExecutivePark

WellesleyHills,MA02481WellesleyHills,MA02481

1|Generalinformation

Employername
LutherCollege / Account/policynumber
235422 / Location / Dateeffective
03/01/2014
Streetaddress
700CollegeDr / City
Decorah / State
IA / Zipcode
52101
Typeof activity:NewEnrollmentChange
Reason: / Occupation

2|Employee information

Employee’sFullLegalName(First,MI,Last)Male
Female / Dateof Birth
StreetAddress / City / State / ZipCode
MaritalStatus / SocialSecurityNumber
[] / Phonenumber
Dateemployed:Full-Time Date:Part-TimeDate:RehireReturnfrom layoffDate:
CurrentActiveEmploymentType
#of hoursFull-TimePart-Time / EmployeeStatus:ManagementSalary
HourlyUnionNon-UnionRetired / Salary

Youneedtocompleteallsectionsof theenrollmentform includingelectingorrefusinginsurancecoveragebelowfrom one of theinsurancecompaniesabove,outsideof NewYork,andsignit.Thismustbedoneeitherduringtheenrollmentperiod orwithin31daysofyoureligibilitydate.Benefitscompletelypaidbyyouremployer(“non-contributorybenefits”)cannotbe refused.Notallof thebenefitoptionslistedbelowwillbenecessarilyavailableto you.Youremployerwilltellyouwhich benefitsareavailableandwhatyourMaximumGuaranteedIssueamountis.SeetheEvidenceof Insurabilitysectionfor details.

3|Benefitelections

OptionalLife[andAD&D]coverage:UnderwrittenbySunLifeAssuranceCompanyof Canada(Wellesley,MA)

Elect / Refuse
Life / Life / Coverageamount elected

Employeecoverage:

Life:

Spousecoverage**:

Life:

Child(ren)coverage**:

Life:

**SpouseandChildrenmayonlybecoveredifyouare.

Youcannotelectmorethan50%ofyouramountof Optionalinsuranceforyourspouseandchild(ren)thanyouhave electedforyourself.

3|Benefitelections,continued

VoluntaryAD&Dcoverage:UnderwrittenbySunLifeAssuranceCompanyof Canada(Wellesley,MA)

ElectRefuse

Employeecoverage:$ Spousecoverage**:$

Child(ren)coverage**:$

Coverageamount elected

**SpouseandChildrenmayonlybecoveredifyouare.

4|Dependentinformation

Pleasecompletethisentiresectionifyouareselectingdependentcoverage.Noemployeecanbeinsuredasadependent whenhe/sheis alsoinsuredasanemployeeforanybenefitunderthesamepolicy.

Ifmorespaceisneeded,pleaseaddadditionalpages.

Relationship / Fulllegalname(First,MI,Last) / Gender / Social Security number / Date of birth / Checkifelected
DepLife
Spouse/
Partner
Children

5|BeneficiaryDesignation information

PrimaryBeneficiaryDesignation

BasicLife [andADD]Insurance–Onthelinesbelow,listtheindividual(s)whoshouldreceiveproceedsintheeventof yourdeath. Youmayspecifyasmanyindividualsasyoulike,butthetotalproceedsmustequal100%.This isyourprimary beneficiary.Attachadditionalpagesifnecessary.Ifyoudo notnameabeneficiaryorifno beneficiaryisaliveat thetimeof yourdeath,proceedswillbepayableinaccordancewithyourGroupinsurancepolicy.

PrimaryBeneficiary(ies)Percentshare of proceeds*

1Name(First,M.I.,Last) / Relationshiptoemployee / SocialSecuritynumber / %
Address / Phonenumber / Dateof birth
2Name(First,M.I.,Last) / Relationshiptoemployee / SocialSecuritynumber / %
Address / Phonenumber / Dateof birth

*Mustequal100%]

OptionalLife[andAD&D]Insurance–Onthelinesbelow,listtheindividual(s)whoshouldreceiveproceedsintheeventof yourdeath.Youmayspecifyasmanyindividualsasyoulike,butthetotalproceedsmustequal100%.Thisis yourprimary beneficiary.Attachadditionalpagesifnecessary.Ifyoudonotnameabeneficiaryorifnobeneficiaryis aliveatthetimeof yourdeath,proceedswillbepayableinaccordancewithyourGroupinsurancepolicy.

PrimaryBeneficiary(ies)Percentshare of proceeds*

*Mustequal100%]

VoluntaryAD&DInsurance–Onthelinesbelow,listtheindividual(s)whoshouldreceiveproceedsintheeventofyour death.Youmayspecifyasmanyindividualsasyoulike,butthetotalproceedsmustequal100%.Thisisyourprimary beneficiary.Attachadditionalpagesifnecessary.Ifyoudonotnameabeneficiaryorifnobeneficiaryis aliveatthetimeof yourdeath,proceedswillbepayableinaccordancewithyourGroupinsurancepolicy.

PrimaryBeneficiary(ies)Percentshare of proceeds*

*Mustequal100%]

SecondaryBeneficiaryDesignation

BasicLife[andAD&D]Insurance–Onthelinesbelow,listtheindividual(s)whoshouldreceivetheproceedsONLYIFALL of theindividualslistedabovearenotlivingatthetimeofyourdeath.Thisisyoursecondary(orcontingent)beneficiary.The Secondarybeneficiaryis notpaidifyourprimarybeneficiaryis aliveatthetimeofyourdeath.Attachadditionalpagesif necessary.

SecondaryBeneficiary(ies)Percentshare of proceeds*

*Mustequal100%]

OptionalLife[andAD&D]Insurance–Onthelinesbelow,listtheindividual(s)whoshouldreceivetheproceedsONLYIF ALLof theindividualslistedabovearenotlivingatthetimeofyourdeath.Thisisyoursecondary(orcontingent)beneficiary. TheSecondarybeneficiaryis notpaidifyourprimarybeneficiaryis aliveatthetimeofyourdeath.Attachadditionalpagesif necessary.

SecondaryBeneficiary(ies)Percentshare of proceeds*

5|BeneficiaryDesignation information,continued

*Mustequal100%]

VoluntaryAD&DInsurance–Onthelinesbelow,listtheindividual(s)whoshouldreceivetheproceedsONLYIFALLof the individualslistedabovearenotlivingatthetimeofyourdeath.Thisisyoursecondary(orcontingent)beneficiary.The Secondarybeneficiaryis notpaidifyourprimarybeneficiaryis aliveatthetimeofyourdeath.Attachadditionalpagesif necessary.

SecondaryBeneficiary(ies)Percentshare of proceeds*

*Mustequal100%]]

6|Evidenceofinsurabilityandauthorizationinformation

AmedicalEvidenceof Insurability(“EOI”)applicationwillberequiredforanyemployeewhoappliesforcoveragemorethan

31dayspasthis/hereligibilitydate.AnEOIapplicationis alsoneededifyou:

•applyforahighercoveragethantheMaximumGuaranteedIssueamount

•wanttoincreaseyourexistingcoveragenoworatalaterdate,whetheryourexistingcoverageiswithSunLife

AssuranceCompanyof Canadaand/orSunLifeandHealthInsuranceCompany(U.S.)orapriorinsurancecarrier

•declinecoverageandthenwantitatalaterdate

Coverageis subjecttoevidenceof insurabilityandwillnotgointoeffectuntilSunLifeAssuranceCompanyof Canada and/orSunLifeandHealthInsuranceCompany(U.S.)approvesit.

Iunderstandthat:

•Iam requestingcoverageunderaGroupInsurancepolicyofferedbymyemployer.Thiscoveragewillendwhenmy employmentterminates.

•Myemployerwilldeductallorpartof thepremiumforcontributorycoveragefrommypay.

•IfIdeclinecoverageformyselfor,ifapplicable,formyfamilynowandwantitatalaterdate,I/wewillhavetosubmit anEvidenceof Insurabilityapplicationwhichis acceptabletoSunLifeAssuranceCompanyof Canada.Ihaveread theEvidenceof Insurabilitynotice.

•IfIdeclinecoverageforVoluntaryADDanddonotenrollwhenIameligible,Iwillnotbeallowedtoenrollforat least6months.

•IfIamnotactivelyatworkduetoinjury,illness,layofforleaveof absenceonthedatethatanyinitialorincreased coverageis scheduledtostartundertheplan,suchcoveragewillnotstartuntilthedateIreturntowork.

•Whenrequiredbythecoverage,ifmyspouseoranyof mydependentchildrenareconfinedduetoaninjuryor illness, asrequiredbythecoverage,onthedatethatanyinitialorincreasedcoverageis scheduledtostartunderthe plan,suchcoveragewillnotstartuntilthedatetheyarenolongerconfinedandareabletoperformtheirnormal activities.

Bysigningbelow,Iam representingthattheinformationIhaveprovidedis trueandcorrecttothebestofmyknowledge andbelief.

EmployeeSignatureToday’sDate

TotheEmployee:Makeacopyof thisformforyourrecordsbeforesubmittingitto youremployer.

TotheEmployer:Thisoriginalenrollmentform shouldremainattheemployer’ssite.Familystatus,coverage,or beneficiarychangesshouldberecordedonanothercopyof theEnrollmentform.

7|Employerinformation

ForEmployerUseOnly

Providetheemployee’searningsamountbelow.[Mostemployersshouldusethe”AllCoverages”boxonly.However,if yourgrouppolicyrequiresthatyoucalculateseparateearningsamountsbycoverage,pleaseenterthoseamountsinthe secondsetof boxes.]

Indicatepayfrequency.Ifhourly,pleaseindicatethenumberof hoursworkedper week.Althoughmostplansdefine earningsassalary-only(notincludingbonuses,commissions,etc.),youshouldcheckyourgrouppolicyfortheproper earningsdefinitiontouse.

AllCoverage

Earnings

AnnualSemi-MonthlyWeekly

MonthlyBi-Weekly

Hourly

Numberofhoursworkedperweek:

LifeEarnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:
VoluntaryADD Earnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:
STDEarnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:
LTDEarnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:
[CriticalIllness] [CriticalIllness, Cancer-only] [CriticalIllnessand Cancer][Cancer] Earnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:
VoluntaryAccident
Earnings
$ / AnnualSemi-MonthlyWeekly
MonthlyBi-Weekly / Hourly
Numberofhoursworkedperweek:

Contactus

Bymail

SunLifeFinancial

OneSunLifeExecutivePark

WellesleyHills,MA02481

CustomerService800-247-6875M–F8:00a.m.–8:00p.m.,ET

SunLife AssuranceCompany ofCanadaandSunLifeandHealthInsuranceCompany (U.S.)aremembersofthe SunLifeFinancial groupofcompanies.

SunLifeFinancialandtheglobesymbolareregistered trademarksofSunLifeAssuranceCompanyof Canada.

GVMPEM-3255 (8/13)SLF EBGCustomizable EnrollmentFormPage7of78/13