Contact us By mail Sun Life Assurance Company of Canada P.O. Box 9757 Portland, ME 04104 By fax 866.376.9480 By e-mail slfworksiteclaims@yourbenefitexpert.com www.sunlife.com/us Customer Service 877 - 820 - 5306 M–F 8:00 a.m. – 8:00 p.m., ET Sun Life Assurance Company of Canada is a member of the Sun Life group of companies. © 2023 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. The Sun Life name and logo are registered trademarks of Sun Life Assurance Company of Canada. GCIFM-7261 Wellness Benefit Reimbursement 4 of 4 04/23 5 | Fraud warnings , continued O H: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OK : WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OR : Any person who, with intent to defraud or knowingly providing false information may be guilty of fraud and may be subject to civil or criminal penalties. PR : Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. RI : Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. TN and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VA : Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. VT : Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. 6 | Signature I/we understand that all or part of the information provided may be communicated between the Sun Life Assurance Company of Canada (the “Company”) and its affiliates. The information provided may be shared to process transactions that concern any coverage I may have requested or have with the Company or as permitted by law. I have read or had read to me the fraud warning for my state. Claimant name Policy number Claimant signature or authorized representative X Date