- 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.
|Form Name||Form Number|
147077 (rev 9/01/14)
147455 (rev 9/01/14)