Notification of Death
Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies,
is committed to keeping your information confidential.
Please PRINT clearly.

1

To be completed by the administrator or the employer.

Clear

I Member information

If the member is enrolled in
a pre-retirement plan with
Sun Life Group Retirement
Services, please indicate
Contract number and SIN
(Social Insurance Number).

Contract number

Class

Billing group number

Member’s last name

Member ID number

First name

Date of birth (dd-mm-yyyy)

–
Address (street number and name)

Date employment commenced
(dd-mm-yyyy)

–

City

Date last worked
(dd-mm-yyyy)

–

Insurance amount

–
–

–

–

–

If determined by salary or occupation, state salary or occupation:

$

–

Cause of death:
 Accident (Further details may be required.)
 Other (specify) _____________________________________________  Unknown at present

Contract number

Social Insurance Number

I

2

Postal code

If not actively at work at death, state reason:
 Sick leave
 Other (specify) __________________________
 Retired

Date insurance last increased (dd-mm-yyyy)

$
Date of death (dd-mm-yyyy)

Province

–

I

I

I

I

I

I

I

I Dependent information

This statement should
be accompanied by proof
of death.

Employee data
Member’s last name

First name

Date of birth (dd-mm-yyyy)

–
Address (street number and name)

Date employment commenced
(dd-mm-yyyy)

–

–

City

Was employee actively at work
at death of dependent?

 Yes

Province

–
Postal code

If not actively at work at death, date last worked and reason:
(dd-mm-yyyy)
 Sick leave
 Retired

–

 No

–

 Other (specify) ___________________

Dependent data
If dependent is beyond
normal limiting age and
policy provides continued
insurance, forward supporting
documentation (school
attendance letter, medical
report or disability, etc.).

Dependent’s last name

Date of birth (dd-mm-yyyy)

–
Address (street number and name)

Date of death (dd-mm-yyyy)

–

–

Insurance amount

$
3

First name

City

Relationship to employee
 Spouse
 Child
Cause of death:

Province

–
Postal code

 Married
 Other (specify) ___________________________________  Single

 Accident (Further details may be required.)
 Other (specify) ____________________________________________________________

I Signature

NOTE: If your policy is
self-administered, forward the
enrolment and other cards, or
forms. Photocopies are
sufficient for Dependent
Claims.

Group Policyholder name

Address (street number and name)

City

Authorized signature

Province

Postal code

Telephone number

X
Location signed (city)

–
Location signed (province)

–

Date (dd-mm-yyyy)

–

–

Sun Life Assurance Company of Canada, Group Life Claims (602D60), 1155 Metcalfe St, Montreal QC H3B 2V9
020-3252-07-11