Application For Long Term Disability Conversion Insurance printable pdf download

How to Apply for Long Term Disability Conversion Insurance

Please follow these steps to apply for Conversion:

1. Complete the LTD Conversion Application provided in this package. Please answer

each question in full, sign, and date the application form. You do not have to supply

medical evidence of insurability to obtain the converted coverage.

2. The Employer must complete the Group Employer Questionnaire provided in this

package. Some companies will provide you with a Health and Insurance Plans

Conversion/Portability Notice which can be used in lieu of the Group Employer

Questionnaire.

3. Send your:

•

Completed Application for Long Term Disability Conversion Insurance; and

•

Group Employer Questionnaire Form or Health and Insurance Plans

Conversion/Portability Notice to:

Metropolitan Life Insurance Company

FAX: 908-552-3979

MAIL - P.O. Box 30429 / Tampa, FL 33630-3429

PHONE - 1-800-929-1492, prompt 5

EMAIL –

4. The Application and Questionnaire must be returned to our office within 31 days of

the date in which you are terminated, resign or are considered no longer within a

designated class.

The Conversion Privilege is available to you if:

1. If the Conversion Privilege is included within your employer's LTD plan underwritten

by Metropolitan Life Insurance Company (“MetLife”).

2. If you have been insured for a designated length of time under the Conversion

Privilege provided in your employer's LTD plan underwritten by Metropolitan Life

Insurance Company (“MetLife”).

3. Your employment with your employer ends because you:

•

Resign; or

•

Are terminated; or

•

If you no longer reside within a designated class

The Conversion Privilege is not available to you if:

1. You retire;

2. You are disabled under the terms of the employer's LTD plan;

3. The Master Policy providing your LTD coverage terminates;

4. The Master Policy is amended to exclude the class of employee to which you belong;

5. You fail to pay the required contribution; or

6. If you become insured for long term disability coverage under another group plan

within 31 days after termination from your employer's plan.

How will you know if the application is approved or denied:

Once a decision has been reached, Metropolitan Life Insurance Company will promptly

notify you using the contact information provided in the LTD Conversion Application. If

approved, Metropolitan Life Insurance Company will notify you of the following:

1. The Effective Date of coverage;

2. The Benefit Amount;

3. The Elimination Period; and

4. The amount of the Quarterly Premium and any pro-rated amount due.

Application For Long Term Disability Conversion Insurance

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