Form Ci-Port - Request For Portability Of Critical Illness Insurance
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1
2Request for Portability of Critical Illness Insurance*
PLEASE NOTE:
This form must be received by UnitedHealthcare Specialty Benefits within 31 days of Date of Termination
All sections of this form must be complete for us to process your request
The Employee or applicable Dependent will not be eligible to port the Critical Illness coverage if the
Employee has not been insured under the policy for at least 6 months (time limit may vary by state). Refer to
your COC for other eligibility requirements.
Sections A, B and C to be completed by Employer
A. Information about EMPLOYEE
Employee Last Name
First Name
M.I.
Date of Birth
Date of Hire
Employee’s coverage amount
Monthly premium
Initial Effective Date
Date premium paid to
Date of Termination
Reason for Termination
Annual salary at Termination
Social Security Number
B. Information about Spouse and Dependent(s) (Complete only when the Dependent Portability option
is available.)
Monthly
Dependent Name and Relationship
Social Security Number
Date of Birth
Coverage Amount
Premium
C. Employer Information
Employer’s signature
Printed name
Company phone number
Date
Group Name
Group Policy Number
Date this form given to Employee
Sections D, E, F and G to be completed by Employee
D. Employee Information
Address (Street, City, State and ZIP code)
Phone number:
(_____) _______-________
E. Insurance Coverage You Are Requesting To Port
Check appropriate election (you may only port coverage that is shown above by your employer as being in
force and portable per the Group policy):
Employee
Employee and Dependent Spouse
Employee and All Dependents
Employee and Dependent Children
CI-Port (12/12)
*In some states, Portability may be referred to as Continuation
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Parent category: Medical