Colonial Port-Conversion Form - Collateral Benefits Group printable pdf download

Colonial Port-Conversion Form - Collateral Benefits Group

YES! I want to keep my

Colonial Life Coverage.

My premiums are no longer being payroll-deducted.

Complete this form and mail it today — along with a check for your premium payment.

Name: ____________________________________ Daytime Telephone Number: (______) ________________________

Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________

City: ______________________________________ State:_______________________ Zip: _____________________

Policy number(s) to be continued:

______________________,

______________________, ______________________, ______________________,

Which Colonial Life & Accident Insurance do you want to continue? (check one or more)

Accident

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

Deduct premiums each month from my checking account.

Attach a voided check with this form and circle one range of dates you would like your account to be drafted.

Your draft will occur on one of the dates within the range you have selected.

Range: (A) 1st-5th (B) 6th-10th (C) 11th-15th (D) 16th-20th (E) 21st-26th

Signature of Checking Account Owner: _______________________________________________________________

Bill me directly. Choose one of the following:

Quarterly (Submit a payment 3 times your monthly premium)

Semi-annually (Submit a payment 6 times your monthly premium)

Annually (Submit a payment 12 times your monthly premium)

Date: ____________________

Policy Owner’s Signature:______________________________________________

Return To:

Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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Colonial Port-Conversion Form - Collateral Benefits Group