Fillable Individual Life Conversion Request For Information Form printable pdf download

Individual Life Conversion Request For Information Form

This form enables you and your insured dependents to obtain information on any right you may have

to purchase an individual life insurance policy within 31 days after your group life coverage ends or is reduced

because of termination of employment or a change in your classification. Please complete the information

below, if you are interested, and an application and premium costs will be sent. Your application and

premium need to be submitted to this office within 31 days after the date of your group life insurance

ending. Please review the Conversion Privilege provision in your existing Policy (or if unavailable contact the

Employer) to ensure an understanding of your conversion rights, responsibilities and any extension to convert that may be available in your state.

PART A - EMPLOYER OR ADMINISTRATOR TO CERTIFY

Name of Employee/Member

Madison National Life Insurance Company

Name of Policyholder (use name shown in group policy or booklet)

Policy#

Policyholder's Address

Contact Name

DATE OF GROUP LIFE INSURANCE TERMINATION

LAST DATE WORKED

TOTAL AMOUNT OF GROUP LIFE INSURANCE ON TERMINATION DATE

________/________/___________

_____/_____/________

Basic $_______________________ Supplemental $____________________

If the Employee's/Member's insurance was extended beyond the last date worked please indicate the reason for extension:

Employee/Member's Occupation_____________________________Class:__________________ Annual Salary_______/_______/________

Employee/Member's Hrie Date ___/___/___ Employee's/Member's effective date of Group Life Insurance Coverage under the Group Policy: ___/___/___

Did Member have Dependent Life Insurance on Group Plan? ____Yes

_____No

Amount of Spouse Life Insurance $______________________

Amount of Child Life Insurance $___________________________

REASON FOR TERMINATION:

EMPLOYEE

DEPENDENT

___ Termination of Policy

___ Termination of Employment

___ Divorce

___ Disability

___ Marriage of a child

___ Other (please explain)__________________

___ A surviving spouse or child of deceased employee

_______________________________________

___ Other (please explain)__________________

Is Employee/Member Disabled? _____Yes_____No

_______________________________________

Is Employee/Member on Disability?_____ Yes _____No If Yes, did he/she become disabled prior to age 60? ____Yes ____No

Has the insured Member made an Absolute Assignment of the group life insurance to be converted? _______Yes ________No

If yes, please attach a copy of the Absolute Assignment form.

Date on which this Notice was given to Employee/Member _______/________/________

Date Notice Completed

Signature of Employer/Administrator

Title

Phone Number

PART B - TO BE COMPLETED BY EMPLOYEE REQUESTING CONVERSION INFORMATION

Name

Soc Sec #

Date of Birth

Age

Sex

Home Address

Street

City

State

Zip Code

Phone # (

)

Email Address:

If Email address is provided correspondence will be sent via email.

If Spouse or Children are checked above, provide information below:

___Yourself ___ Spouse

___ Children

Name of Dependent(s)

Age

Date of Birth

SS#

Sex

Relationship to you

Employee's Signature___________________________________________________ Date Completed and Mailed_________________________

Mail to:

HRMP Life Conversion Facility, 300 Rosewood Drive, Suite 250, Danvers, MA 01923

Toll Free: (888) 999-4767 Phone: (978) 762-0661 Fax: (978) 762-4767 Email:

Individual Life Conversion Request For Information Form

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