TERM LIFE COVERAGE CONTINUATION 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.

Term Life Coverage Continuation Request form

• This is used ONLY for groups that have the optional portability benefit for life coverage. Check your certificate for details before distributing this form.
• Remember to complete the Employer sections of the form before distributing the form to the insured person.
• If ownership of 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: The owner of coverage must also receive the Conversion Information Request Form along with this form.