Portability Of Insurance Form For Former Dependent Child
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1
2PORTABILITY OF INSURANCE FOR FORMER DEPENDENT CHILD
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_______________________________________ Social Security Number ______________________
Dependent Child Coverage Termination Date:
______________
Month/Day/Year
Reason for Dependent Child's Coverage Termination:
Age
No Longer Full-Time Student
Other
________________________________________________________
Have premiums been paid for this child through the coverage termination date:
Yes
No
Employer Signature______________________________________________________________ Date ______________
Month/Day/Year
NOTE TO EMPLOYER: Please review the group policy regarding portability limitations.
TO BE COMPLETED BY EMPLOYEE:
Please print (preferably in black ink).
Former Dependent
Child's Name______________________________________________ Social Security Number ______________________
Gender:
Male
Female
Birthdate ___________
Month/Day/Year
Street Address____________________________________________ City_______________ State______ Zip_________
Day Phone ___________________ Evening Phone _________________
TO BE COMPLETED BY FORMER DEPENDENT CHILD:
1.
Indicate the amount of coverage you wish to continue:
$25,000
$50,000*
* Please note, the Insurance Company will issue you $25,000 of coverage as guarantee issue, but you will need to satisfy medical
evidence of insurability to obtain $50,000 of coverage. The Insurance Company will send you an evidence of insurability
form to complete.
2.
You must specify a beneficiary(ies) by completing the section below. When specifying multiple beneficiaries, you must indicate the
percentage of distribution for each and the total must equal 100%. If there is not enough room to specify all beneficiaries, attach,
sign and date a separate sheet of paper using the format below.
Beneficiary
Percentage
Social Security #
Date of Birth
Relationship
Month/Day/Year
Former Dependent
Child's Signature_________________________________________ Date ________________
Please Sign Here
Month/Day/Year
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LM-600827b (08/06)
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