Form Lm-601040g - Portability Of Basic And Voluntary Trem Life Insurance

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PORTABILITY OF BASIC AND VOLUNTARY TERM LIFE INSURANCE

(Employee, Spouse and Child/ren)

Life Insurance Company of North America

Group Insurance

Life Accident Disability

Please print (preferably in black ink).

EMPLOYER USE SECTION: TO BE COMPLETED BY THE EMPLOYER

Employer____________________________________________________________________ Policy # _____________________

Name of Employee______________________________________________________________ Class _______________________

Basic Coverage Amount Eligible to Port:

Employee _____________

Voluntary Coverage Amount Eligible to Port:

Employee _____________

Spouse ____________

Child _____________

Coverage Termination Date: ______________

Employment Termination Date: ______________

Month/Day/Year

Reason for Termination of Group Insurance:

Termination of Employment

Cancellation of Group Contract

Reduction in Benefit

Other __________________

Change to Another Class

Retirement

Disability

Date Notice Provided: ______________

Month/Day/Year

Employer Signature____________________________________________________________________ Date ______________

Month/Day/Year

NOTE TO EMPLOYER: Be sure to check the group policy regarding portability limitations and assignments. Notice

must be provided to the Owner of this coverage. The Owner may be other than the employee or dependent.

**NOTE: THIS FORM IS TO BE COMPLETED BY THE OWNER OF THIS COVERAGE.**

EMPLOYEE INFORMATION

Please print (preferably in black ink).

Home Address____________________________________________ City________________________ State______ Zip_________

Day Phone __________________ Evening Phone ________________ Social Security #___________________ Birthdate _____________

Month/Day/Year

1. If you wish to continue your basic and/or voluntary coverage, please check one for basic, and one for voluntary:

Continue amount of basic employer-paid coverage currently in force or

Decrease the coverage amount to ____________ (Units of $1,000)

Continue amount of voluntary coverage currently in force or

Decrease the coverage amount to ____________ (Units of $1,000)

Check here if you want to increase your coverage. See item #5 in General Information.

3. Have you smoked or used any form of tobacco in the last 12 months?

Yes

4. Have you applied for: (Check all that apply.)

Conversion

Application Date: _______________

Month/Day/Year

Waiver of Premium

Application Date: _______________

Month/Day/Year

Accelerated Benefit/Terminal Illness Benefit

Application Date: _______________

Month/Day/Year

SPOUSE INFORMATION

Spouse's Name __________________________________________ Social Security #___________________ Birthdate _____________

Month/Day/Year

1. If you wish to continue voluntary coverage for your spouse, please check one:

Continue amount of coverage currently in force or

Decrease the coverage amount to ____________ (Units of $1,000)

Check here if you want to increase spouse coverage. See item #5 in General Information.

Has your spouse smoked or used any form of tobacco in the last 12 months?

Yes

Has your spouse applied for: (Check all that apply.)

Conversion

Application Date: _______________

Month/Day/Year

Accelerated Benefit/Terminal Illness Benefit

Application Date: _______________

Month/Day/Year

CHILD/REN INFORMATION

Do you wish to continue your children coverage?

Yes

Children who are no longer eligible, as defined in the group policy, and who wish to continue their coverage may apply for either $25,000 or $50,000 of term

coverage by completing the Child Portability Form. Please contact NEBCO at the phone number shown on page 2 and they will provide you with this form. Please note,

you cannot port child coverage unless the child meets the age and dependency requirements as defined in the group policy.

LM-601040g (08/06)

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