LONG TERM DISABILITY (MONTHLY INCOME BENEFITS) CONVERSION INFORMATI0N REQUEST FORM

The forms provided here are standard Administration forms. See the other links on the sidebar for Claim Forms. If any form you need is listed as "TBD" then please contact your Account Representative to order a paper supply as indicated in your Administration Manual. Any Enrollment forms and Evidence of Insurability forms must be obtained through your local Account Representative.

Long Term Disability (Monthly Income Benefits) Conversion Information Request Form

• Not all groups have this option: check your certificate.
• Use this form when employee long term disability coverage (monthly income benefits) becomes eligible for conversion.
• Check your certificate for the Conditions for Conversion. Residents of these states are NOT eligible for conversion: FL, IN, LA, MI, NY, OR, SD and WV.
• Remember to complete the Employer's section of the form and attach a current Schedule of Benefits before distributing the form to the employee.