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Don't know your network name? You can find your network name on your dental ID card. If you do not have a dental ID card available, you can access it on your Sun Life account.
www.sunlife.com/us Public website where potential clients can learn about and do business with us. Access online secure portal where brokers can view block of business and commission statements. Employers can administer benefits and pay bills online. Members can view claim statuses. Providers can view account details.
Sun Life and Health Insurance Company Administered by: Sun Life Financial PO Box 2941 Clinton Iowa 52733 KC2147ANY (10/2016) 14-a Employee/subscriber name (if different than patient’s) 14-b Employee/subscriber Soc. Sec. or I.D. no. 14-c birthdate MO DAY YR 15 Relationship to patient Self Parent Spouse Other 11 12-aIs patient covered by another
In all states except New York, insurance products and prepaid dental products are underwritten or provided by Sun Life Assurance Company of Canada (Wellesley Hills, MA) (“SLOC”) and by Union Security Insurance Company (Kansas City, MO), administered by SLOC.
If your designation does not fit into one of the sections below please contact your HR representative or Sun Life Financial for assistance. For your convenience, a FAQ regarding beneficiary designations is available on our website at www.assurantemployeebenefits.com. Please review and complete the back of this form, as applicable.
Short Term Disability Claim Statement Union Security Life Insurance Company of New York Administered by: Sun Life Financial PO Box 972208 El Paso Texas 79997-2208 • T 888.901.6377 • F 866.439.1695 • KCBeneļ¬ tCenter@ sunlife .com Page 1 of 8 KC0384ANY(05/2017) For your protection, the following disclosures are required by state law and are based on the state where you live:
A claim for Group Life Insurance benefits should be submitted to Sun Life Financial as soon as notice is received that an employee/dependent or the employee’s beneficiary is eligible for benefits. Filing of a Claim
Insurance products are underwritten by Union Security Insurance Company (Kansas City, MO) under Policy Form Series GP-10 and administered by Sun Life Assurance Company of Canada (Wellesley Hills, MA).
This question should be completed if your company had LTD coverage through a different carrier, immediately prior to your Sun Life Financial’s coverage. If applicable, provide us with the claimant’s effective and termination dates under the prior plan .