(Monthly Income Benefits)
- 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.
|Form Name||Form Number|
43736f (115671) (rev 9/01/14)