SLF RF10 PRD2 3/7/2013 9:23:38 AM PAGE 4/006 Fax Server

Death Claim Submission form••H~•..4.~

Sun~}Life Financial @

Please note:

• Return this form along with a certified death certificate for the deceased.• If there is more than one beneficiary, each beneficiary must complete a separate form .

•For questions or help with this form, call us at 800-862-6266 .•For policies issued in New York, call us at 877-750-8683.

r.··poiICY·~~b~~'~i·'······""""'·······":"::':":..: : ::::.: · ·..· ·.·.·.·.·.i.i

linsured:sname·.·.·........... ·.JSSN/TiN . ..i

o I have enclosed my policy with this form.

o I am unable to locate the policy referenced above. If I find it, I will immediately return it to the Company.

!··AddreSS·· · .

! ·CltY· .. · .. ········· ····· .. ·· ······ ·:.. ·s;;,t~· !Zip ·.. .

......................................................................................................................................................................···············t··D;Yti~~·ph~~~····················..··································1In case we need to contact you about this request j j

: ••••••• 0_ ••••••••• 00 •• 0 ••••••• , ••••••••••• 0 ••••••••••••••••••••• 0 ••••• 0 ••••••• ~

• If the beneficiary is a person, please complete the Person as Beneficiary section.• If the beneficiary is an entity, please complete the Entity as Beneficiary section.• If the beneficiary is an estate, please complete the Estate as Beneficiary section.• If the beneficiary is a trust, please complete the Trust as Beneficiary section.

Person as beneficiary:..B~~~fi~i~ry·f~·iii;;g~·i;;;;;;;~· · · ·..· ,

: ::--SSN/TiN · · ·.. · · · ·· ..~.. ·R;;i~ti;;~h·ip·t;th;;·d·.;;,-.:~~·d ·..· · i..D~·t~·;;f·birth · ··..·..· · · · · ;

L : __ __. __ _ , _ ~_ _ _. ._._. __._ _ _ _._ _._ ~

Entity as beneficiary (we require a corporate resolution to evidence any officer's signing authority)[--EntitY-~~;;;;;·--·--········---···--··-··-·····--·---··- - -- -.--- -..---- - __ __ __ _-_ __ - ---- ------ -- j

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Sun Ufe Assurance Company of Canada and Sun Ufe Assurance Company of Canada (U.S.) issued policies in Puerto Rico, the District of Columbia, andall states except New York. Sun Life Insurance and Annuity Company of New York issued policies in New York. Each of these companies isresponsible for its own financial condition and contractual obligations. The Company that issued the policy referenced above is referred to as"Company" within this form.

,D2(YI1. Sun Life Assurance Company of Canada {U.S.).At! ~ight~;reserved. Sun UfE Fii!a~cial3.i!d th~ globe ~::yr!lbo!are registered trademarks of s~:!t.ife Assurance Company of Canada.

U3Flv1-1 536-IND [Rf':V1012.-09-17]

SLF RF10 PRD2 3/7/2013 9:23:38 AM PAGE 5/006 Fax Server

Estate as beneficiary~~'8t;,t~'~'~;;;~""""-""""""""""""""-"'" ~

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Trust as beneficiaryf··i-~·~;~~~·-········································· " "' " - _--..- :

I certify that:

(1) The taxpayer identification number provided on this form is the correct one, or that I am waiting for a number to be issued tome, and

(2) I am not subject to backup withholding because (a) I am exempt from backup withholding, (b) I have not been notified by theInternal Revenue Service (IRS)that I am subject to backup withholding as a result of failure to report all interest or dividends, or(c) the IRShas notified me that I am no longer subject to backup withholding, and

(3) I am a U.S.citizen or other U.S.person.

Certification instructions: You must cross out item 2 if you have been notified by the IRSthat you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 doesnot apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to anindividual retirement arrangement (IRA),and generally, payments other than interest and dividends, you are not required to sign thecertification, but you must provide your correct TIN.

I agree that this claim form is being supplied at the undersigned's request and without any verification by the Company or its affiliatesas to whether any insurance is in force and, if so, whether any benefit is due. Acceptance of this signed form may not be considered awaiver of any rights or defenses by the Company or its affiliates.

If you are signing this form as a fiduciary for the beneficiary (power of attorney, trustee, guardian, custodian, etc.), please sign in yourfiduciary capacity. We will need your authorizing documents to process this request. If we do not have them on file, please attachthem to this form.

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(8~By mail"=,,, Sun Life Financial

P.O. Box 9106Wellesley Hills, MA 02481- 9106

-.....•.('+) By express mail'---./ Sun Life Financial

One Sun Life Executive ParkWellesley Hills, MA 02481

~ By fax,- ....: 888-863-8311

~'\ www.sunlife.comz'us~~~}----------------------------------

"--:-,,t.£,) Customer Service M-F 8:00 a.m.-6:00 p.m., ET~-~ 800-862-6266 for policies issued in all states except New York

877-750- 8683 for policies issued in New York

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