- 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.
|Form Name||Form Number|
44316g (115717) (rev 9/01/14)
124104 (rev 9/01/14)