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Sun Life Assurance Company of Canada - PDF - PDF

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                                                                                        Sun Life Assurance
                                                                                       Company of Canada
                                                                                                   SC3225
                                                                                One Sun Life Executive Park
                                                                                        Wellesley Hills MA
                                                                                               02481-5699
                                                                                             1-800-247-6875

                               Sun Life Assurance Company of Canada
                                       Headquarters Office: U.S.A.
                                   Identification Statement of Children

Re: Group Policy Number:                                41030
Social Security Number:
Employee Name:
Policy Holder Name:                                     Jarden Corporation

I,                                          , residing at
                          , state that I have known                                          for
years. My relationship to                                            is                             . I
certify that the following are the Full Names and Dates of Birth (Death if deceased) of all children the
said                                         ever had*. There is no posthumous or legally adopted child,
unless mentioned below. I also state that I have no interest in these life insurance proceeds under Group
policy number 41030.

*We will need to have certified copies of death certificates of any deceased children listed below in order
to proceed with our review of this claim.

Name of Children           Date of Birth                Date of Death             Place of Last Residence




Witnessed by Notary Public
State of                                          County of

On this day of                             , 20    before me personally came

                                           , who signed the above statement knowingly and willingly.
WITNESS, my hand and official seal:
Official Seal:                                            Signature – Notary Public


                                                          Printed Name


                                                          Commission Expiration Date

                                                          Sun Life Assurance Company of Canada
                                                          is a member of the Sun Life Financial group of
                                                          companies.

                                                          www.sunlife-usa.com               SLPC 7554

								
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