Portability Of Insurance Form For Former Dependent Child Page 2
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1
2Former Dependent
Child's Name_______________________________________________________ Social Security Number ______________________
GENERAL INFORMATION
1.
Eligibility — Children who were covered but are no longer eligible due to reaching the maximum age stated in the certificate of
insurance under either parent's Term Life program. You have 31 days from the date of no longer being eligible to apply for
portability.
2.
Coverage Options — You can elect either $25,000 or $50,000 in life coverage. The first $25,000 is guaranteed. If applying for
$50,000, you must satisfy the insurability requirements for the amount over $25,000.
3.
Rates — Please note that rates for ported coverage will be higher than those paid previously, and they are subject to change. If you
would like an estimated premium before applying for coverage, please call 1-800-423-1282.
4
Deadline — You have 31 days from the Coverage Termination Date to exercise the portability option.
.
5.
Effective Date — The effective date of your ported coverage will be the first day of the month following the Coverage Termination
Date.
6.
Billing — You will be billed on a quarterly basis. After the initial bill, you will receive your bill approximately 30 days in advance of
the due date. In order to keep your coverage in force, you must pay your premiums promptly.
7.
Beneficiary(ies) — In the event of your death, benefits will be paid to the beneficiary, the person named on page 1 of this
document. Changes may be made to the beneficiary by sending written notice to the address below.
Complete this form, sign and date, and return to: NEBCO, P.O. Box 152501, Irving, TX 75015-2501
For Questions, please call 1-800-423-1282, 8:00 a.m. to 4:30 p.m., CST.
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LM-600827b (08/06)
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