LIFE CONVERSION INFORMATION REQUEST FORM

The forms provided here are standard Administration forms. See the other links on the sidebar for Claim Forms. Any Enrollment forms and Evidence of Insurability forms must be obtained through your local Account Representative.

Life Conversion Information Request Form

• Use this form when employee and/or dependent life coverage becomes eligible for conversion.
• Check your certificate for the Conditions for Conversion.
• Remember to complete the Employer's section before distributing the form to the insured person(s).
• If ownership of employee coverage is assigned, the form must be distributed to the owner instead of to the insured person.
• NOTE: There are time limits that pertain to your distribution of this form and the recipient's return of the completed form to the insurance company. See your certificate for details.
• NOTE: This form must be provided each time life coverage becomes eligible for conversion, even if the insured person may also be eligible for other benefits under the policy.