CONTINUING YOUR GROUP TERM LIFE INSURANCE

Save this PDF as:

Size: px
Start display at page:

Download "CONTINUING YOUR GROUP TERM LIFE INSURANCE"

Transcription

1 CONTINUING YOUR GROUP TERM LIFE INSURANCE Liberty Life Assurance Company of Boston (Instructions and Application) You may elect to continue your Optional Group Life Insurance, and that of your Dependent Spouse, without evidence of insurability if your insurance ends for any reason, other than retirement and you do not convert any part of the Optional Group Life Insurance which is scheduled to terminate. The effective date of the requested coverage (Portable Group Term Life Insurance) will be 12:01 am standard time on the day after coverage under the group plan ends, provided: you have submitted Liberty's Application for Portable Group Term Life Insurance (form PTL-APP.2) within 31 days of the date you are no longer eligible under your employer's group plan; and Liberty has received the required premium and application fee. SECTION ONE - YOU ARE ELIGIBLE FOR PORTABLE GROUP TERM LIFE INSURANCE IF: You elect Portable Group Term Life Insurance within 31 days of the date your Group Life Insurance terminates. You are under age 70. You are not a full time member of the armed forces of any country. You are a citizen or resident of the United States or Canada. No Group Life Insurance on you will continue with Liberty Life Assurance Company of Boston on a premium paying or premium waiver basis. You have not elected an individual Conversion Insurance policy. SECTION TWO - HOW TO APPLY: EMPLOYER: When you learn that an employee is terminating, complete the section captioned TO BE COMPLETED BY EMPLOYER on the back side of the application and give this form to the employee. EMPLOYEE: 1. Complete the attached application. 2. Be sure the application is signed and dated. Detach the application and attach to it your check made payable to Liberty Life Assurance Company of Boston for the required premium and application fee. 3. The application and check must be received no later than 31 days after termination of your group life insurance by: LIBERTY LIFE ASSURANCE COMPANY OF BOSTON c/o JHA Service Center P.O. Box 7146 Portland, ME PTL- INST.2 (General - Optional Life amount) 1

2 SECTION THREE - SUMMARY OF PORTABLE GROUP TERM LIFE INSURANCE BENEFITS: Employee and Dependent Spouse Amount of Insurance Benefits Maximum & Minimum Amounts Maximum amount of Portable Group Term Life Insurance available to you is equal to the lesser of the amount of Optional Group Life Insurance that terminates, or $500,000. Minimum amount of Portable Group Term Life Insurance is $10,000. The amount of insurance available for your Dependent Spouse is the amount that terminated under the group life insurance plan. Increasing & Decreasing Amounts The amount of Portable Group Term Life Insurance can be decreased at any time. However, once elected, the amount of Portable Group Term Life Insurance on you or your Dependent Spouse can not be increased. Employee and Spouse insurance benefits will reduce to 65% of the inforce amount at age 65. Termination Provisions The Participant (You) will cease to be insured on the earliest of the following dates: the date you fail to pay the required premiums. the date you attain age 70. five (5) years from the effective date of your Portable Group Term Life Insurance the date you are approved for Premium Waiver under the former plan with Liberty. the date you elect an individual Life Insurance Conversion Policy on the amount of insurance that terminated. the date you become a full time member of the armed forces of any country. Your Dependent Spouse will cease to be insured on the earliest of the following dates: the date your Spouse attains age 70. the date the Spouse goes on active duty in the armed forces of any country. the date Group Portable Term Life Insurance coverage ends for you, the Employee. SECTION FOUR - CALCULATING THE PREMIUM DUE: Premium rates per $1,000 Age at Birthday closest to application date Quarterly Mode Annually Mode Less than $.279 $.300 $.330 $.435 $.660 $1.170 $1.833 $2.889 $4.170 $6.954 $1.116 $1.200 $1.320 $1.740 $2.640 $4.680 $7.332 $ $ $ PTL- INST.2 (General - Optional Life amount) 2

3 SECTION FOUR - CALCULATING THE PREMIUM DUE: (Continued) How to calculate your premium EXAMPLE: Quarterly premium for an individual whose birthday is 10/22 and application date is 1/1/99 requesting $50,000 of Portable Group Term Life Insurance coverage. The closest birthday to the application date would be 10/22/98. The applicant uses his/her age on that date. We will use age 35. Premium rate per $1,000 is $.435 $50,000 requested amount divided by 1,000 = x 50 = $21.75; Rates are not guaranteed and may be changed at any time with a 31-day notice. Age banded rates are reviewed and communicated to you on each policy anniversary. Employee Premium Worksheet 1. Determine age at birthday closest to the application date 2. $ Premium rate per $1,000 (from premium rate table stated on page 2, based on your age at time of application and selected payment frequency) 3. $ Amount of insurance requested (item 12 in the Employee section on the application) 4. Divide the amount in item 3 by 1,000 (Example; 10,000 in requested insurance would equal 10) 5. $ Multiply the amount of item 4 by the amount in item 2. (This equals your premium amount for the payment frequency you selected.) If you selected Dependent Spouse coverage, you must do the same type of calculation using your Spouse's information. Dependent Spouse Premium Worksheet 6. Determine age of Dependent Spouse at birthday closest to the application date 7. $ Premium rate per $1,000 (from premium rate table stated on page 2, based on your dependent spouse's age at time of application and your selected payment frequency) 8. $ Amount of insurance requested (item 12 in the Employee section on the application) 9. Divide the amount in item 8 by 1,000 (Example; 10,000 in requested insurance would equal 10) 10. $ Multiply the amount of item 9 by the amount in item 7. Totaling the Premium Worksheet 11. $ Combine the amount in item 5 with the amount in item 10. (This is the premium due for the payment frequency you selected.) 12. $ Add the $25.00 non-refundable application fee to the amount in item $ Please remit this amount when submitting your application. If you have any questions, you may contact the JHA Service Center, Inc. at the following number: PTL- INST.2 (General - Optional Life amount) 3

4 APPLICATION FOR PORTABLE GROUP TERM LIFE INSURANCE Liberty Life Assurance Company of Boston How to Apply: This form completed by the applicant, together with a check made payable to Liberty Life Assurance company of Boston for the first premium must be received within 31 days after termination of group coverage at: LIBERTY LIFE ASSURANCE COMPANY OF BOSTON, c/o JHA Service Center, P.O. Box 7146, Portland, ME TO BE COMPLETED BY APPLICANT I have the right to apply for a Portable Group Life Insurance Certificate under the terms of Group Life Insurance Policy Number: 1. Name (Last, First, Middle Initial) 2. Sex 3. Social Security Number [ ] Male [ ] Female 4. Home Address (Street, City, Street, Zip) 5. Date of Birth [6. Dependent Spouse Name [7. Dependent Spouse Sex [8. SS# and Date of Birth] (Last, First, Middle Initial)] [ ] Male [ ] Female] 9. Date you were no longer eligible for the group life insurance: 10. What was your job with the above Employer? 12. Amount of insurance requested? (Must be less than or equal to the optional coverage terminated under the Group Life plan) Applicant Amount $ [Dependent Amount $ ] 14. Amount of premium submitted with the application? $ (See Instructions, page 3, line 13) 17. Additional Instructions: 15. Primary Beneficiary of the Applicant (See the reverse side of this form) 11. Plan of Insurance PORTABLE GROUP TERM LIFE 13. How will premiums be paid? [ ] Annually [ ] Quarterly 16. Contingent Beneficiary of the Applicant THE STATEMENTS ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND I AGREE THAT THEY SHALL FORM A PART OF THE CONTRACT OF INSURANCE APPLIED FOR. I UNDERSTAND THAT ANY PERSON WHO KNOWINGLY OR WITH INTNENT TO INJURE, DEFRAUD OR DECEIVE AN INSURANCE COMPANY, FILES A STATEMENT CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW. Signature of Applicant Date Upon approval of this application, a certificate of coverage will be sent directly to you at the address provided. NOTE: Employer MUST complete information required on reverse side. PTL - APP. 2 (General - Optional Life amount)

5 TO BE COMPLETED BY EMPLOYER 1. Employer (Firm Name and Division) 2. Employer s Address (Street, City, Street, Zip) 3. Group Life Policy Number 4. Name of Person Eligible for Portable Group Term Life Insurance 5. Date of Birth (mm/dd/yy) 6. Sex [ ] Male [ ] Female 7. Date Eligibility for Group Life Insurance Ceased* 8. Amount of Optional Group Life Insurance which is terminated 9. Date this Person was first Insured under the Group Life Insurance Policy Applicant Amount $ [Dependent Amount $ ] 10. Reason for Termination of Person s Group Life Insurance [ ] Employment terminated or membership in an eligible class terminated [ ] Class of eligible persons terminated 11. Employer Representative Signature Date: INFORMATION ABOUT BENEFICIARIES The person(s) designated as Beneficiary on the application will receive the amount of insurance upon the death of the Applicant. The Beneficiary for Dependent Spouse coverage is the applicant listed on the reverse side of this form. You may name more than one Primary Beneficiary if you wish. All Primary Beneficiaries who survive the applicant, will share equally in the insurance benefits. You may name more than one Contingent Beneficiary who will receive the benefits if the Primary Beneficiary should die before you. If more than one contingent Beneficiary is named, all Contingent Beneficiaries who survive the Applicant will share equally. When naming Beneficiaries, please follow this example: a. PRIMARY BENEFICIARY: Mary J. Doe, Wife b. CONTINGENT BENEFICIARY: John P. Doe, Son NOTE: If a Beneficiary is a married woman, use her given name, for example Mary J. Doe and not Mrs. John Doe. If a beneficiary is not related to you, use the term no relation and enter the Beneficiary s address in Question 17. NOTE: BOTH SIDES OF THIS APPLICATION MUST BE COMPLETED. PTL - APP. 2 (General - Optional Life amount)

Southwest Airlines Group Life Portability Insurance Application. Standard Insurance Company INSTRUCTIONS PLEASE READ CAREFULLY

Southwest Airlines Group Life Portability Insurance Application. Standard Insurance Company INSTRUCTIONS PLEASE READ CAREFULLY 920 SW Sixth Avenue Portland OR 97204-1203 800.378.4668 ext. 6785 Group Life Portability Insurance Application INSTRUCTIONS PLEASE READ CAREFULLY Portability Of Insurance You may be eligible to buy portable

More information

Standard Insurance Company 920 SW Sixth Avenue Portland OR 97204-1203 800.378.4668 ext. 6785. Group Life Portability Insurance Application

Standard Insurance Company 920 SW Sixth Avenue Portland OR 97204-1203 800.378.4668 ext. 6785. Group Life Portability Insurance Application 920 SW Sixth Avenue Portland OR 97204-1203 800.378.4668 ext. 6785 Group Life Portability Insurance Application INSTRUCTIONS PLEASE READ CAREFULLY Portability Of Insurance You may be eligible to buy portable

More information

Application for Conversion of Group Term Life Insurance

Application for Conversion of Group Term Life Insurance Application for Conversion of Group Term Life Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate or policy.

More information

CONVERSION OF GROUP OR EMPLOYEE LIFE INSURANCE TO AN INDIVIDUAL POLICY

CONVERSION OF GROUP OR EMPLOYEE LIFE INSURANCE TO AN INDIVIDUAL POLICY CONVERSION OF GROUP OR EMPLOYEE LIFE INSURANCE TO AN INDIVIDUAL POLICY Life Insurance Company of North America Group Insurance Life Accident Disability What is the conversion privilege? The right of an

More information

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate

More information

Application for Conversion of Group Term Life Insurance

Application for Conversion of Group Term Life Insurance Application for Conversion of Group Term Life Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate or policy.

More information

Continue your Aetna life insurance coverage with this option.

Continue your Aetna life insurance coverage with this option. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with this option. Thank you for your interest

More information

LIFE INSURANCE NOTIFICATION OF CONVERSION PRIVILEGE Unum Life Insurance Company of America (Unum)

LIFE INSURANCE NOTIFICATION OF CONVERSION PRIVILEGE Unum Life Insurance Company of America (Unum) LIFE INSURANCE NOTIFICATION OF CONVERSION PRIVILEGE Unum Life Insurance Company of America (Unum) 1. Conversion rights When your group life insurance terminates or the amount of coverage you have is reduced,

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with these options. Thank you for your interest

More information

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate:

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate: CONVERSION OF GROUP TERM LIFE INSURANCE Subject to the terms of the Group Policy, as described in your group insurance certificate: (1) you may apply for an individual, permanent life insurance policy

More information

Application for Conversion of Group Term Life & Accidental Death Insurance Aetna Life Insurance Company

Application for Conversion of Group Term Life & Accidental Death Insurance Aetna Life Insurance Company Application for Conversion of Group Term Life & Accidental Death Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate

More information

Life insurance protection after group coverage ends

Life insurance protection after group coverage ends Group Life Insurance Portability Kit Life insurance protection after group coverage ends LDM-6249 1/14 Don t leave your group life insurance behind. You know how important it is to own life insurance.

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Life Enrollment & Billing Services 151 Farmington Avenue, RT32 Hartford, CT 06156 Need more information? Log onto www.aetna.com, or call us at 1-800-523-5065 Continue your Aetna life insurance coverage

More information

You can convert your term life insurance.

You can convert your term life insurance. Turning promise into practice TM You can convert your term life insurance. When you terminate employment or insurance eligibility, or you retire, you have options available regarding your current group

More information

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate:

CONVERSION OF GROUP TERM LIFE INSURANCE. Subject to the terms of the Group Policy, as described in your group insurance certificate: CONVERSION OF GROUP TERM LIFE INSURANCE Subject to the terms of the Group Policy, as described in your group insurance certificate: (1) you may apply for an individual, permanent life insurance policy

More information

Group Term Life Insurance Continuation Form

Group Term Life Insurance Continuation Form Group Term Life Insurance Continuation Form Employees must be actively at work at the time of employment termination or retirement in order to be eligible for the continuation plan. Coverage terminates

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form You may apply for Group Term Life Insurance coverage under Prudential s portability option. This option may be available to you and your covered dependents

More information

Application to Continue/Port or Convert Group Insurance

Application to Continue/Port or Convert Group Insurance Application to Continue/Port or Convert Group Insurance Products and financial services provided by American United Life Insurance Company a OneAmerica company One American Square, P.O. Box 7106 Indianapolis,

More information

Portability Option for Group Term Life Insurance

Portability Option for Group Term Life Insurance Instructions 1. Employer Please Print 2. Employee Please read the Fraud Notice on the back of the form, before completing. Please Print Portability Option for Group Term Life Insurance Aetna Life Insurance

More information

ANNUITY APPLICATION. State. State

ANNUITY APPLICATION. State. State 2. Full Name of Proposed Annuitant POLISH NATIONAL UNION of AMERICA referred to as the PNU - A Fraternal Benefit Society 1002 Pittston Avenue Scranton, PA 18505 1-800-724-6352 or 570-344-1513 1. Is Proposed

More information

CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS

CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS CONTINUATION OF GROUP TERM LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE EMPLOYER INSTRUCTIONS Employees who have either terminated or lost coverage have 31 days from either their termination

More information

SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance

SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance SPECIAL OFFER TO ELIGIBLE FEDERAL GOVERNMENT EMPLOYEES $50,000 Group Term Life Insurance New York Life Insurance Company 1, one of the largest and most respected life insurance companies in the nation

More information

VOLUNTARY GROUP TERM LIFE INSURANCE:

VOLUNTARY GROUP TERM LIFE INSURANCE: VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan

More information

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Sponsored by: Xavier University All Full-Time Employees excluding Jesuit Employees Life Benefit Employee Spouse

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with these options. Thank you for your interest

More information

First Unum Life Insurance Company

First Unum Life Insurance Company First Unum Life Insurance Company 1. Conversion rights When your group life insurance terminates or the amount of coverage you have is reduced, you can convert your coverage to any available Policy offered

More information

Important Information About MetLife s Portability Option

Important Information About MetLife s Portability Option Election of Portable Coverage Form For Group Life Insurance Coverage Metropolitan Life Insurance Company Important Information About MetLife s Portability Option You re in a time of transition, and MetLife

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

The United States Life Insurance Company in the City of New York New York, New York A member company of American International Group, Inc.

The United States Life Insurance Company in the City of New York New York, New York A member company of American International Group, Inc. The United States Life Insurance Company in the City of New York New York, New York A member company of American International Group, Inc. Received $ from in connection with application for conversion

More information

State of Maryland Group Term Life Insurance Answers to your questions about coverage from Standard Insurance Company

State of Maryland Group Term Life Insurance Answers to your questions about coverage from Standard Insurance Company State of Maryland Group Term Life Insurance Answers to your questions about coverage from Standard Insurance Company STANDARD INSURANCE COMPANY About This Booklet This booklet is designed to answer some

More information

Long Term Disability Insurance Conversion Plan

Long Term Disability Insurance Conversion Plan Long Term Disability Insurance Conversion Plan The Prudential Insurance Company of America INST-A002112-A Long Term Disability Insurance Conversion Plan If you have any questions regarding the conversion

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Life Enrollment & Billing Services 151 Farmington Avenue, RT32 Hartford, CT 06156 Need more information? Log onto www.aetna.com, or call us at 1-800-523-5065 Continue your Aetna life insurance coverage

More information

Important Information About MetLife s Portability Option

Important Information About MetLife s Portability Option Election of Portable Coverage Form For Group Life and Accidental Death & Dismemberment (AD&D) Insurance Coverage Metropolitan Life Insurance Company Important Information About MetLife s Portability Option

More information

Employer Instructions for Filing Group Life Insurance Claims. 1. Detach this page and complete the Employer s Statement on the following page.

Employer Instructions for Filing Group Life Insurance Claims. 1. Detach this page and complete the Employer s Statement on the following page. Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give the beneficiary the remaining pages

More information

Voluntary Term Life Program Specifications Prepared For. Gunnison County

Voluntary Term Life Program Specifications Prepared For. Gunnison County Voluntary Term Life Program Specifications Prepared For Gunnison County The Lincoln National Life Insurance Company 8801 Indian Hills Drive, Omaha, NE 68114 VOLUNTARY TERM LIFE INSURANCE Employee Gunnison

More information

Helpful Information for Completing the Authorization for Lifetime Annuity Payments from TIAA-CREF Group/Supplemental Retirement Annuities

Helpful Information for Completing the Authorization for Lifetime Annuity Payments from TIAA-CREF Group/Supplemental Retirement Annuities P.O. Box 1268 Charlotte NC 28201-1268 Helpful Information for Completing the Authorization for Lifetime Annuity Payments from TIAA-CREF Group/Supplemental Retirement Annuities Complete and return this

More information

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS

Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Voluntary Life Insurance with Accidental Death and Dismemberment (AD&D) SUMMARY OF BENEFITS Sponsored by: Clarksville-Montgomery County Employees Life Benefit Employee Spouse Dependent Amount Choice of

More information

Public Employees' Retirement System of Mississippi Brings You: Group Term Life Insurance

Public Employees' Retirement System of Mississippi Brings You: Group Term Life Insurance Public Employees' Retirement System of Mississippi Brings You: Group Term Life Insurance What is it, what does it cover, how can you apply? Answers to your questions about your PERS insurance plan About

More information

The Company You Keep. Life Insurance. Conversion Instructions G-230G (11/08)

The Company You Keep. Life Insurance. Conversion Instructions G-230G (11/08) The Company You Keep Life Insurance Conversion Instructions G-230G (11/08) You are receiving this package because your Group Term Life Insurance will soon be terminating. Under the Group Term Life Insurance

More information

Supplemental Term Life Insurance Plan

Supplemental Term Life Insurance Plan Supplemental Term Life Insurance Plan JANUARY 1, 2006 Who Is Eligible Service Requirement Eligibility Date Dependent Age Limit Employee-Only Coverage Options Spouse-Only Coverage Options Children-Only

More information

Important Information About MetLife s Portability Option

Important Information About MetLife s Portability Option Metropolitan Life Insurance Company Election of Portable Coverage Form For Group Life Insurance Coverage Important Information About MetLife s Portability Option You re in a time of transition, and MetLife

More information

Additional Life Coverage Highlights Kent State University

Additional Life Coverage Highlights Kent State University Additional Life Coverage Highlights Additional Life Insurance will provide Basic Life coverage from Standard Insurance Company. If you are enrolled in Basic Life, you may also apply for Additional Life

More information

Extra Protection For Your Family

Extra Protection For Your Family IDAHO Extra Protection For Your Family Group Decreasing Term Life Insurance The Voice for Public Pensions The Prudential Insurance Company of America 0182925-00001-00 The Voice for Public Pensions Dear

More information

The Prudential Insurance Company of America

The Prudential Insurance Company of America The Prudential Insurance Company of America Record Keeping Services PO Box 13676 Philadelphia, PA 19176 (800) 778-3827 Dear New Uniformed Firefighter: The City of Chicago is committed to offering a benefits

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

and You ve made a good decision July 1, 2014 02 Class: anthem.com Life and Disability

and You ve made a good decision July 1, 2014 02 Class: anthem.com Life and Disability Group Term Life and AD&D Insurance A guide to your benefits You ve made a good decision in choosing Anthem Life Plan Sponsor: Effective Date: Class: Class Description: Foothills Gateway, Inc. July 1, 2014

More information

hy should you consider purchasing life insurance protection at your workplace?

hy should you consider purchasing life insurance protection at your workplace? W hy should you consider purchasing life insurance protection at your workplace? Employees find significant value in obtaining non-medical products in their workplace. Many of us lead busy lives and seldom

More information

Voluntary Group Accidental Death & Dismemberment Insurance

Voluntary Group Accidental Death & Dismemberment Insurance Voluntary Group Accidental Death & Dismemberment Insurance 0159298 American Foreign Service Protective Association Voluntary Group Accidental Death & Dismemberment Insurance Plan Protect the Ones You Love

More information

Extra Protection For Your Family

Extra Protection For Your Family ILLINOIS Extra Protection For Your Family Group Decreasing Term Life Insurance National Conference on Public Employee Retirement Systems The Prudential Insurance Company of America 0204989-00002-00 Ed.

More information

THE UNITED STATES LIFE Insurance Company In the City of New York

THE UNITED STATES LIFE Insurance Company In the City of New York THE UNITED STATES LIFE Insurance Company In the City of New York (Called United States Life) United States Life will pay the benefits of this policy subject to its provisions. This page and the pages that

More information

If the proceeds are payable to a minor, the guardian of the minor s estate should complete this form.

If the proceeds are payable to a minor, the guardian of the minor s estate should complete this form. INSTRUCTIONS The following information will be required in order to process benefits for the Annuity Policy 1. Completed Claimant Statement 2. Certified Death Certificate 3. Original Annuity Policy Form

More information

Long Term Disability Conversion Insurance Application Instructions For Residents of: AR, CO, DC, KY, LA, NJ, NM, NY, OH, OK, PA, TN

Long Term Disability Conversion Insurance Application Instructions For Residents of: AR, CO, DC, KY, LA, NJ, NM, NY, OH, OK, PA, TN Long Term Disability Conversion Insurance Application Instructions THE RIGHT TO CONVERT If your long term disability (LTD) insurance ends under your Employer s Group LTD Policy from Standard Insurance

More information

CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND

CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND CITYWIDE ASSOCIATION OF LAW ASSISTANTS OF THE CIVIL, CRIMINAL AND FAMILY COURTS IN THE CITY OF NEW YORK WELFARE TRUST FUND C/O ADMINISTRATIVE SERVICES ONLY, INC 303 MERRICK ROAD, SUITE 300 LYNBROOK, NY

More information

Employer Instructions for Filing Group Life Insurance Claims

Employer Instructions for Filing Group Life Insurance Claims Metropolitan Life Insurance Company Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give

More information

GROUP INSURANCE STATE OF LOUISIANA

GROUP INSURANCE STATE OF LOUISIANA Y O U R E N R O L L M E N T K I T GROUP INSURANCE Basic Term Life Insurance Basic Term Life & Supplemental Term Life Insurance Accidental Death & Dismemberment (AD&D) Insurance Dependent Term Life Insurance

More information

University System of Maryland. Your Group Life Insurance Plan

University System of Maryland. Your Group Life Insurance Plan University System of Maryland Your Group Life Insurance Plan Identification No. 115327 011 Underwritten by Unum Life Insurance Company of America 7/9/2013 CERTIFICATE OF COVERAGE The Group Insurance Policy

More information

Employer Instructions for Filing Group Life Insurance Claims

Employer Instructions for Filing Group Life Insurance Claims Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give the beneficiary the remaining pages

More information

Life Insurance Conversion Notification of Conversion Privilege

Life Insurance Conversion Notification of Conversion Privilege Life Insurance Conversion Notification of Conversion Privilege Employer completes this section Company Name Group Policy and Division Number Employee s Name Date of Birth (dd/mm/yyyy) Group life insurance

More information

Ten Year Term Life Insurance Renewable Term

Ten Year Term Life Insurance Renewable Term Ten Year Term Life Insurance Renewable Term Premiums are Guaranteed for the Life of the Contract Convertible Non-Participating Western Life Assurance Company P.O. Box 3300 Winnipeg, Manitoba R3C 5S2 A

More information

EMPLOYEE LIFE INSURANCE

EMPLOYEE LIFE INSURANCE EMPLOYEE LIFE INSURANCE Life Benefit The Insurer will pay the amount of life insurance in force on the employee at the date of death provided that the Insurer receives due proof that the employee died

More information

President and Trustees of Bates College. Your Group Life and Accidental Death and Dismemberment Plan

President and Trustees of Bates College. Your Group Life and Accidental Death and Dismemberment Plan President and Trustees of Bates College Your Group Life and Accidental Death and Dismemberment Plan Identification No. 128121 012 Underwritten by Unum Life Insurance Company of America 11/21/2012 CERTIFICATE

More information

Toronto District School Board GROUP LIFE INSURANCE FOR TEACHERS

Toronto District School Board GROUP LIFE INSURANCE FOR TEACHERS INTRODUCTION Toronto District School Board GROUP LIFE INSURANCE FOR TEACHERS This group life insurance plan, under policy G. 10450 with Canada Life, originated in 1971. It is managed by a joint Management

More information

Act Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit

Act Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit Act Now! You must apply within 60 days of termination GIVE YOUR FAMILY PEAK PROTECTION Group Long Term Disability Insurance Conversion Plan Enrollment Kit Customer Service Center 888-262-6873 Monday through

More information

APPLICATION FOR CONVERSION OF GROUP LIFE

APPLICATION FOR CONVERSION OF GROUP LIFE INSTRUCTIONS 1. Complete the application in its entirety, then sign and date it. 2. Mail pages 1-3 of the application with the premium to: The Prudential Insurance Company of America Prudential/Group Life

More information

FG Guarantee-Platinum 5 Year Product

FG Guarantee-Platinum 5 Year Product 5 Year Product Applications for the 5 year product must be submitted electronically. Please log on to Saleslink for additional details at https://www.fglife.com. Fidelity & Guaranty Life SM is the marketing

More information

The Accelerated Benefits Option ( ABO )

The Accelerated Benefits Option ( ABO ) The Accelerated Benefits Option ( ABO ) Metropolitan Life Insurance Company Group Life Claims Telephone Number: 1-800-638-6420 Please read the following important information before completing the attached

More information

Your Life Insurance Guide

Your Life Insurance Guide Your Life Insurance Guide 646522-A Standard Insurance Company Life Insurance Life insurance coverage can help your family meet daily expenses, maintain their standard of living, pay off debt, secure your

More information

MBA S TRICARE Supplement Insurance Plan

MBA S TRICARE Supplement Insurance Plan Underwritten by : Hartford Life Insurance Company and Hartford Life and Accident Insurance Company THREE TRICARE OPTIONS MBA S TRICARE Supplement Insurance Plan This Supplement Plan provides maximum protection

More information

Unum Life Insurance Company of America insures the lives of. City of Moberly. under the Select Group Insurance Trust Policy No.

Unum Life Insurance Company of America insures the lives of. City of Moberly. under the Select Group Insurance Trust Policy No. GROUP INSURANCE SUMMARY OF BENEFITS NON-PARTICIPATING IDENTIFICATION NUMBER: 420359 001 EFFECTIVE DATE OF COVERAGE: January 1, 2016 ANNIVERSARY DATE: January 1 GOVERNING JURISDICTION: Maine Unum Life Insurance

More information

VOLUNTARY GROUP TERM LIFE INSURANCE: GUARANTEED ISSUE:

VOLUNTARY GROUP TERM LIFE INSURANCE: GUARANTEED ISSUE: VOLUNTARY GROUP TERM LIFE INSURANCE: This plan offers you and your dependents an excellent opportunity to purchase affordable group term life insurance on a payroll deduction basis. The important plan

More information

The Prudential Insurance Company of America

The Prudential Insurance Company of America Basic Term Life Insurance Accidental Death and Dismemberment Insurance Optional Term Life Insurance Dependent Term Life Insurance Optional Accidental Death and Dismemberment Insurance The Prudential Insurance

More information

New Employee Enrollment. COMMONWEALTH OF KENTUCKY Enrollment Brochure and Booklet Certificate

New Employee Enrollment. COMMONWEALTH OF KENTUCKY Enrollment Brochure and Booklet Certificate New Employee Enrollment COMMONWEALTH OF KENTUCKY Enrollment Brochure and Booklet Certificate Group Term Life Insurance The Commonwealth of Kentucky is pleased to offer you Group Term Life Insurance and

More information

City of Tuscaloosa GVTL-AE3M Revised: January 1, 2016 All Eligible Employees

City of Tuscaloosa GVTL-AE3M Revised: January 1, 2016 All Eligible Employees City of Tuscaloosa GVTL-AE3M Revised: January 1, 2016 All Eligible Employees This Summary of Coverage provides a brief description of some of the terms, conditions, exclusions and limitations of Your employer

More information

United of Omaha Life Insurance Company A Mutual of Omaha Company. voluntary term life insurance. work. for you UGC8914_0409

United of Omaha Life Insurance Company A Mutual of Omaha Company. voluntary term life insurance. work. for you UGC8914_0409 United of Omaha Life Insurance Company A Mutual of Omaha Company voluntary term life insurance Benefits work that for you UGC8914_0409 Eligibility All full-time employees, who are citizens or permanent

More information

State of Louisiana All Employees

State of Louisiana All Employees State of Louisiana All Employees Basic Term Life Insurance Basic plus Supplemental Term Life Insurance Accidental Death and Dismemberment Insurance Dependent Term Life Insurance The Prudential Insurance

More information

Flexible Purchase Payment Deferred Annuity Application United of Omaha Life Insurance Company Home Office: Mutual of Omaha Plaza Omaha, Nebraska 68175

Flexible Purchase Payment Deferred Annuity Application United of Omaha Life Insurance Company Home Office: Mutual of Omaha Plaza Omaha, Nebraska 68175 Flexible Purchase Payment Deferred Annuity Application United of Omaha Life Insurance Company Home Office: Mutual of Omaha Plaza Omaha, Nebraska 68175 Amount Paid with Application $ 1 Type of Plan: Non-Qualified

More information

Optional and Dependent Life Group Insurance Plan 112687.011

Optional and Dependent Life Group Insurance Plan 112687.011 Optional and Dependent Life Group Insurance Plan 112687.011 CERTIFICATE OF COVERAGE Unum Life Insurance Company of America (referred to as Unum) welcomes you as a client. This is your certificate of coverage

More information

Dependent Life Insurance Plan

Dependent Life Insurance Plan Dependent Life Insurance Plan Lowe's offers the Lowe's Dependent Term Life Insurance Plan (the Dependent Term Life Plan Option), insured through Cigna, to help with expenses related to the death of a dependent.

More information

Dependent Life Insurance Plan

Dependent Life Insurance Plan Dependent Life Insurance Plan Lowe's offers the Lowe's Dependent Term Life Insurance Plan (the Dependent Term Life Plan Option), insured through MetLife, to help with expenses related to the death of a

More information

ELECTION TO CONTINUE YOUR LONG TERM CARE INSURANCE COVERAGE

ELECTION TO CONTINUE YOUR LONG TERM CARE INSURANCE COVERAGE ELECTION TO CONTINUE YOUR LONG TERM CARE INSURANCE COVERAGE Mail to: Unum Life Insurance Company of America LTC Customer Services 2211 Congress Street Portland, Maine 04122 Policy Number: TO BE COMPLETED

More information

Manage your Liberty Mutual group benefits online.

Manage your Liberty Mutual group benefits online. Manage your Liberty Mutual group benefits online. MyLibertyConnection.com offers convenient access to online tools to help you manage your group benefits. To get started, visit www.mylibertyconnection.com

More information

Group Term Life/AD&D Insurance

Group Term Life/AD&D Insurance Group Term Life/AD&D Insurance You ve made a good decision in choosing Anthem Blue Cross Life and Health Plan Sponsor: Policy: Class: 01 Class Desc.: Cupertino Union School District C20797 Effective Date:

More information

Orange County Transportation Authority- Administrative Group

Orange County Transportation Authority- Administrative Group Group Life Insurance SUMMARY OF BENEFITS Life and AD&D Sponsored by: All Full-Time Administrative Employees and Employees represented by Transportation Communications Union (TCU) Life Employee Amount Two

More information

Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created

Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created a settlement option, the Total Control Account Money

More information

Your life insurance conversion privilege

Your life insurance conversion privilege Your life insurance conversion privilege GROUP INSURANCE When your employment terminates, or when you retire or reach the policy age limit, your group life insurance coverages could be cancelled or reduced.

More information

City of Moberly. Your Group Life and Accidental Death and Dismemberment Plan

City of Moberly. Your Group Life and Accidental Death and Dismemberment Plan City of Moberly Your Group Life and Accidental Death and Dismemberment Plan Identification No. 420359 011 Underwritten by Unum Life Insurance Company of America 12/4/2015 CERTIFICATE OF COVERAGE Unum

More information

SAMPLE. Benefits derived from the election of multiple service with the Public School Employees' Retirement System.

SAMPLE. Benefits derived from the election of multiple service with the Public School Employees' Retirement System. COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM SERS CENTRAL COUNSELING - OUT OF STATE 30 N 3RD STREET SUITE 150 HARRISBURG, PA 17101-1716 800 633-5461 www.sers.state.pa.us Region 99 APPLICATION

More information

A Guide for Successfully Completing the Mutual of Omaha Group Disability Continuation Request Form

A Guide for Successfully Completing the Mutual of Omaha Group Disability Continuation Request Form A Guide for Successfully Completing the Mutual of Omaha Group Disability Continuation Request Form Mutual of Omaha appreciates the opportunity to provide you with continued disability insurance protection.

More information

QMA LIFE INSURANCE. Program. Complete the application provided, and mail to: Apply Now! Québec Medical Association

QMA LIFE INSURANCE. Program. Complete the application provided, and mail to: Apply Now! Québec Medical Association QMA LIFE INSURANCE Program Apply Now! Complete the application provided, and mail to: Québec Medical Association 380 1000 Saint-Antoine de la Gauchetière West West Suite 3200 660 Montréal Montreal (Québec)

More information

EMPLOYER S STATEMENT

EMPLOYER S STATEMENT Liberty Life Assurance Company of Boston TO BE COMPLETED BY EMPLOYER Employee s Name, Address & Phone No. EMPLOYER S STATEMENT Mail to: Group Market Disability Claims Liberty Life Assurance Company of

More information

Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Issued by: Standard Insruance Company For new employees of ENROLLMENT CONDUCTED BY: 1410 Piedmont Drive E. Tallahassee, FL 32308 800.330.6115

More information

CHURCH LIFE INSURANCE CORPORATION

CHURCH LIFE INSURANCE CORPORATION 445 Fifth Avenue New York, NY 10016 (866) 802-6333 (212) 592-1800 CHURCH LIFE INSURANCE CORPORATION THIS POLICY RIDER IS IN CONJUNCTION WITH THE GROUP INSURANCE POLICY AND CERTIFICATE NO. GL2005 IS ISSUED

More information

Life Short Term Disability

Life Short Term Disability a lifetime of commitment c o m p a n i o n b u s i n e s s plan f o r groups of 2 t h r o u g h 9 e m p l o y e e s www.companionlife.com Life Short Term Disability Approximately 30 percent of all people

More information

Financial protection for what matters most

Financial protection for what matters most OAK HARBOR FREIGHT LINES INCORPORATED PO BOX 1469 AUBURN, WA 98071 Don t miss your chance to sign up for this valuable coverage. Enroll by November 30, 2015. Financial protection for what matters most

More information

Your Life Insurance Guide

Your Life Insurance Guide Your Life Insurance Guide 646524-A Standard Insurance Company Life Insurance Life insurance coverage can help your family meet daily expenses, maintain their standard of living, pay off debt, secure your

More information

How You Can Continue Your Group Term Life Insurance (Portability)

How You Can Continue Your Group Term Life Insurance (Portability) 1-888-252-3607 How You Can Continue Your Group Term Life Insurance (Portability) What is Portability? Portability or porting is an optional feature chosen by your former employer. It allows employees and

More information

Your guide to Term Insurance

Your guide to Term Insurance Protection Solutions Your guide to Term Insurance with Standard Life Making Retirement Better Grow. Protect. Live. Transfer. Hello. More and more people are looking for financial security that will get

More information

Thomson Reuters Holding, Inc. Your Group Life and Accidental Death and Dismemberment Plan

Thomson Reuters Holding, Inc. Your Group Life and Accidental Death and Dismemberment Plan Thomson Reuters Holding, Inc. Your Group Life and Accidental Death and Dismemberment Plan Identification No. 351921 141 Underwritten by Unum Life Insurance Company of America 10/28/2010 CERTIFICATE OF

More information

YES! You CAN take it with you

YES! You CAN take it with you YES! You CAN take it with you You Are Now Eligible To Convert Your Current Long-Term Disability Insurance To Disability Conversion Insurance DCI Coverage For residents of New York State Group Insurance

More information

Your Life Insurance Guide

Your Life Insurance Guide Your Life Insurance Guide 646527-A Standard Insurance Company Life Insurance Life insurance coverage can help your family meet daily expenses, maintain their standard of living, pay off debt, secure your

More information