Term Life Insurance Change And Evidence Of Insurability Forms
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1
2Term Life Insurance Change Form
For information and
customer service,
Life Insurance Company of North America
call 1-800-732-1603
Group Insurance
Philadelphia, PA
Life Accident Disability
EMPLOYER USE (MANDATORY DATA NEEDED): In order for the insurance company to process this application, the employer must complete
this information.
EMPLOYER__________________________________________________________________POLICY #______________________
CLASS_______ LOCATION/PAYCODE # ______ DATE OF HIRE____________ ANNUAL SALARY________ VERIFIED BY ___________
REASON FOR REQUEST:
LIFE STATUS CHANGE
ONGOING ENROLLMENT EVENT
REINSTATEMENT
VOLUNTARY EMPLOYEE
VOLUNTARY SPOUSE
VOLUNTARY CHILD
NEW COVERAGE (TOTAL)
CURRENT COVERAGE
GUARANTEED COVERAGE
PORTION OF REQUESTED INCREASE
AMOUNT SUBJECT TO
MEDICAL EVIDENCE
Please print (preferably in black ink).
EMPLOYEE SECTION
Mr.
Mrs.
Ms. (Check One)
Employee Name (First)__________________ (Last)_____________________ Social Security #_________________ Birthdate ____________
Address__________________________________________________ City________________________ State______ Zip_________
Work Phone ____________________ Home Phone _____________________ Sex:
M
F
Height: ____ft ____in Weight: ______lbs
COMPLETE IF ELECTING SPOUSE COVERAGE
I am currently married and my date of marriage is ______________
Name (First)______________________ (Last)___________________________ Social Security #___________________
Spouse
Information
Birthdate _____________________
Sex:
M
F
Height: ______ft ______in
Weight: _______lbs
I WISH TO MAKE THE FOLLOWING CHANGES TO MY LIFE INSURANCE COVERAGE
See your life insurance brochure/application for the coverage election options for your plan. When selecting new coverage amounts, please
ensure that your election(s) match the amounts, salary multiples or unit increments described in your brochure and/or application.
CHECK THE APPROPRIATE BOXES:
Increase, decrease or begin coverage on the following individuals as indicated below:
(Complete the medical questions on the next page for each person electing or increasing coverage)
Current Voluntary Coverage
New Voluntary Coverage
Total Voluntary Coverage
Employee
Spouse
Child(ren)
Answer if your plan includes smoker/non-smoker rates:
Have you smoked or used any form of tobacco in the last 12 months? Employee:
Yes
No
Spouse:
Yes
No
Life Status Change
If this change is being made due to a Life Status Change, please check one of the following, and provide date of change.
Marriage
Divorce
Annulment
Legal Separation
Birth or Adoption of a Child
Death of a Spouse or Child
Leave of Absence
Change in Spouse’s Employment
Return to or from Military Duty
Change from full to part-time (or vice-versa)
Date of Life Status Change ______________
Cancel coverage on the following individuals:
Employee
Spouse
Child(ren)
Effective Date of Cancellation ________________
Cancel the Automatic Increase Option
Name Change: (Current Name / New Name)
Employee_____________________________________/____________________________________
Spouse ______________________________________/_____________________________________
Employee Signature ___________________________________________________ Date ______________
Return to your employer. Be sure to make a copy of your form for your own records.
LM-618458
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