EX-5.(C) 4 a2039432zex-5_c.txt EXHIBIT 5(C) FORM OF REVISED APP. CERTIFICATE -------------------------------------------------- [Logo] SUN LIFE ASSURANCE COMPANY OF CANADA (U.S.) [PRODUCT NAME] Retirement Products and Services [1-8##-###-####] P.O. Box [###] Boston, MA [#####] OR One Copley Place Boston, MA 02116 -------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- A OWNER(S)/ Name * --------------------------------------------------------------------------------------------------- PARTICIPANT(S) Address --------------------------------------------------------------------------------------------------- City State Zip --------------------------------------------------- ----------------- ----------------- Date of Birth / / Social Security Number - - Gender / / M / / F --------------------- * IF A TRUST IS DESIGNATED AS AN OWNER/PARTICIPANT, A VERIFICATION OF TRUST FORM OR TRUST DOCUMENTS MUST ACCOMPANY THIS APPLICATION. ----------------------------------------------------------------------------------------------------------------------------------- B ANNUITANT / / Same as Owner(s)/Participant(s), or Name: ------------------------------------------------------------------------------------ Date of Birth / / Social Security Number - - Gender / / M / / F --------------------- CO-ANNUITANT Name ---------------------------------------------------------------------------------------------------- (OPTIONAL) Date of Birth / / Social Security Number - - Gender / / M / / F --------------------- ----------------------------------------------------------------------------------------------------------------------------------- C PLAN / / Non-Qualified / / CRT (CRT WAIVER MUST ACCOMPANY THIS APPLICATION) SELECTION ---- / / IRA / / IRA Transfer / / IRA Rollover / / Roth IRA / / 403(b) / / 403(b) Partial Transfer (BY CHECKING THIS BOX, OWNER/PARTICIPANT Rollover/Transfer CERTIFIES THAT THE FUNDS TRANSFERRED CONTINUE TO BE SUBJECT TO THE SAME OR MORE STRINGENT DISTRIBUTION RESTRICTIONS AS PRIOR TO THE TRANSFER.) / / Qualified Plan -- TYPE Trustee --------------- -------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- D BENEFICIARY Name Social Security Number Date of Birth Relationship to INFORMATION Owner/Participant /X/ Primary - - / / ------------- ---------------------- ------------- ----------------- / / Primary / / Contingent - - / / ------------- ---------------------- ------------- ----------------- / / Primary / / Contingent - - / / ------------- ---------------------- ------------- ----------------- / / Please check here if you are attaching additional Beneficiary information BENEFICIARY DESIGNATIONS MUST BE CONSISTENT WITH YOUR APPLICABLE RETIREMENT PLAN. FOR NON-QUALIFIED CONTRACTS, THE CONTRACT/CERTIFICATE MAY BE CONTINUED AFTER THE DEATH OF AN OWNER/PARTICIPANT IF THE OWNER/PARTICIPANT'S SPOUSE IS THE BENEFICIARY; OTHERWISE, THE DEATH BENEFIT MUST BE DISTRIBUTED. UNLESS SPECIFIED OTHERWISE, THE DEATH BENEFIT WILL BE DIVIDED EQUALLY AMONG ALL PRIMARY BENEFICIARIES WHO SURVIVE THE OWNER/PARTICIPANT. IF NO PRIMARY BENEFICIARY SURVIVES THE OWNER/PARTICIPANT, THE DEATH BENEFIT WILL BE DIVIDED EQUALLY AMONG ANY CONTINGENT BENEFICIARIES WHO SURVIVE THE OWNER/PARTICIPANT. ----------------------------------------------------------------------------------------------------------------------------------- E OPTIONAL DEATH BENEFIT RIDER (SUBJECT TO STATE AVAILABILITY AND AGE RESTRICTIONS) Optional Death Benefits may ONLY be chosen at time of application. Optional Death Benefits are offered as an enhancement to the basic Death Benefit described in the prospectus. IF AN OPTIONAL RIDER IS NOT ELECTED, THE BASIC DEATH BENEFIT WILL BE PAID TO THE BENEFICIARY UPON THE DEATH OF AN OWNER/PARTICIPANT. Optional Death Benefits cannot be chosen if an Owner/Participant is age 80 or older at the time of application. ONCE ELECTED THIS OPTION MAY NOT BE CHANGED. Choose option(s) from EITHER Package I or Package II PACKAGE I: select any one, any two or all three PACKAGE II: select ONLY one / / Maximum Anniversary Account Value Benefit / / Earnings Enhancement Rider (EEB) Plus / / Earnings Enhancement Rider (EEB) / / Earnings Enhancement Rider (EEB) Plus MAV / / 5% Premium Roll-up Benefit / / Earnings Enhancement Rider (EEB) Plus 5% (THESE OPTIONAL DEATH BENEFITS MAY NOT BE COMBINED WITH ANY OTHER OPTIONAL DEATH BENEFIT.) ----------------------------------------------------------------------------------------------------------------------------------- F SPECIAL (Transfer Company Information; Additional Beneficiaries; Annuity Commencement Date; Annuity Option election, INSTRUCTIONS etc.) ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------- G REPLACEMENT Will this Contract/Certificate replace or change any existing life insurance or annuity in this or any other company? / / Yes / / No If YES, please explain in Section F, SPECIAL INSTRUCTIONS and request replacement information from your Registered Representative. ----------------------------------------------------------------------------------------------------------------------------------- H PURCHASE Please indicate how you would like your Purchase Payment allocated and use whole percentages. Your allocations PAYMENT should Total 100%. This allocation will be used for future investments, unless otherwise specified. ALLOCATION INITIAL PURCHASE PAYMENT $ Minimum initial purchase payment $10,000. ---------------- Make check payable to SUN LIFE (Please estimate dollar amount for 1035 exchanges, transfers, OF CANADA (U.S.). rollovers, etc.) RFF-APP-REV-1-01
-------------------------------------------------- [Logo] SUN LIFE ASSURANCE COMPANY OF CANADA (U.S.) [ PRODUCT NAME ] Retirement Products and Services [1-8##-###-####] P.O. Box [###] Boston, MA [#####] OR One Copley Place Boston, MA 02116 -------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- SUB-ACCOUNTS [ P _______% -------% R _______% -------% O _______% -------% D _______% -------% U _______% -------% C _______% -------% T _______% ] -------% N APPLY 60-DAY RATE HOLD -------% A / / Yes / / No -------% M ESTIMATED DOLLAR AMOUNT -------% E ] $ -------% --------------------------------- -------% NOTE: A RATE HOLD IS IRREVOCABLE AND IS ONLY AVAILABLE FOR 1035 -------% EXCHANGES AND DIRECT TRUSTEE- TO-TRUSTEE TRANSFERS. ----- --------------- ------------------------------------------------------------------------------------------- I ACCEPTANCE I hereby represent that my answers to the questions on this Application are correct and true to the best of my knowledge and belief. ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT/CERTIFICATE WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF WHICH MAY RESULT IN UPWARD AND DOWNWARD ADJUSTMENTS IN AMOUNTS PAYABLE. I have read the applicable fraud warning for my state listed below. I acknowledge receipt of current product and fund prospectuses. ---------------------------------------------- ---------------------------------------- Owner/Participant Signature(s) Date -------------------------------------------------------- ---------------------------- SIGNED AT City State ----- --------------- ------------------------------------------------------------------------------------------- J REGISTERED Will this Contract/Certificate replace or change any existing life insurance or annuity in this or any other company? / / Yes / / No REPRESENTATIVE If YES, please explain in Section F, SPECIAL INSTRUCTIONS and complete replacement forms where applicable. Signature of Registered Registered Representative's Representative Name (print) ---------------- ----------------- Broker/Dealer Branch Office Address ---------------- ----------------- Telephone Number City State Zip ---------------- ---------- --- ------------ Broker/Dealer Account # ----------------------- ------------------------- --------------------------------------------------------------------------------------- FRAUD WARNINGS For applicants in: ARKANSAS, KENTUCKY, MAINE, NEW MEXICO, OHIO AND PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. For applicants in NEW JERSEY: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. For applicants in the DISTRICT OF COLUMBIA "WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR PURPOSES OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT." For applicants in COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. For applicants in FLORIDA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. AGENT'S FLORIDA LICENSE ID NUMBER: ---------------------------------------------------
RFF-APP-REV-1-01