Standard Life Insurance Group Conversion Packet Request
Standard Insurance Company Request for Group Life - Continued Benefits
920 SW Sixth Avenue, Portland, OR 97204 800.378.4668 Tel
Conversion Materials
Important Information for Owners of Group Life Insurance Certificates
We are happy to inform you that under your Standard Insurance Company Group Life Insurance coverage, you and your insured dependents are offered the benefit of obtaining an individual life insurance policy. In order to take advantage of this opportunity, we must receive an application and premium payment within 31 days of the date of cessation or reduction of group life insurance coverage. This option to convert may be very valuable to you, as evidence of insurability will not be required. To take advantage of the privilege of converting your insurance, please complete and return this form to the address above. We will provide the necessary forms and information. For your convenience, at your election, we can send the information electronically to your email address or we can mail the forms to your street address.
| MEMBER INFORMATION | |||
| Member's Name | Today's Date | ||
| Insured's Name, if different | Phone | ||
| Member's Address | City | State | Zip |
| Email Address | |||
| Please indicate the applications you will need. Member Spouse Child No. of children: | Please send application forms via: E-mail Regular Mail | ||
| Group Name and Policy No. | Termination or Reduction Date of Insurance | ||
