Group Life Insurance Portability Form
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4The Standard Life Insurance Company of New York
Notice of Option to Continue
Group Life Insurance/Portability
800.378.4668 Tel 800.331.3397 Fax
Of Insurance Application
920 SW Sixth Avenue Portland OR 97204-1203
INSTRUCTIONS - PLEASE READ CAREFULLY
Portability Of Insurance Notice
You may continue your Life Insurance and other insurance eligible for portability as shown in your Certifi cate if your employment
with the Employer terminates. If you do not continue your Life Insurance, you may not continue any other Insurance.
The minimum and maximum amounts of Insurance eligible for Portability Of Insurance are shown in your Certifi cate. The
amounts of Insurance you continue cannot be increased. Insurance amounts will be reduced or terminated according to the
terms of the Group Policy in effect on the date your employment terminates.
The maximum amount of Life Insurance you may continue is the lesser of: (1) the amount in effect on the date your employment
terminates; or (2) $300,000. The minimum amount of Life Insurance you may continue is $25,000.
NOTE: Refer to Right To Convert in your Certifi cate for information regarding eligibility to convert to an individual life
insurance policy. The amount of Insurance you continue will be reduced by any amount of Insurance you convert.
How To Apply
You must apply in writing and pay the fi rst premium to us within 31 days after the date your employment terminates. This packet
has two forms: one for you and one for the Policyholder. All questions on these forms must be completed. If you
have questions, please contact our offi ce at the phone number shown above. You are responsible for making sure all required
forms are completed and returned to our offi ce. Processing will begin when both completed forms are received by us.
Premium rates are shown in your Certifi cate, and are subject to increase with advancing age. Premium rates may be changed
by The Standard Life Insurance Company of New York with advance written notice. If approved, you will be billed quarterly
(every three months), at your home address. Premium must be received by the due date. There is no grace period for Portability
Of Insurance. Checks are to be payable to The Standard Life Insurance Company of New York.
Keep your Certifi cate. It is your certifi cate of coverage for your continued insurance under the Portability Of Insurance provision.
Please note that Insurance continued under the Portability Of Insurance provision ends automatically on the earliest of:
1.
The date it would otherwise end under the Group Policy.
2.
The date you become insured under any other group life insurance plan.
3.
For any Dependent, the date you insure the Dependent under any other group life insurance plan.
Benefi ciary Designation
Please provide us with the beneficiary designation form on file with the Policyholder. If you cannot provide that
form, or if you wish to change your benefi ciary designation, please complete the Benefi ciary section on Page 3. If we do not
receive the form and if you do not complete the Benefi ciary section on Page 3, you will not have a designated benefi ciary. In
that event, payment of any benefi t will be made in accordance with the Benefi ciary Provisions of the Group Policy.
Printed 05/11/2010
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SNY 15159
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