Graduate Medical Education

Standard Group Conversion Request for Long Term Disability Insurance

REGENTS, University of California
Group Long Term Disability
Policy 643159

INSTRUCTIONS FOR CONVERTING YOUR GROUP
LONG TERM DISABILITY INSURANCE

  1. Complete the LTD Conversion Request form below (SI 14-4781) and mail to Standard Insurance Company within 31 days of terminating your employment. 
  2. Standard Insurance Company will mail you a packet containing the following materials:
    • Conversion Application
    • Rates and Premium information
    • Description of the conversion policy (includes benefit information)
  3. You will have 31 days to return the application along with the first premium payment if you choose to convert your policy.
  4. If you have general LTD Conversion questions or would like to check on the status of your application, please call our Conversion Department at 1-800-378-4668, ext. 6785
 

Standard Insurance Company Request for Long Term Disability

920 SW Sixth Avenue Portland, OR 97204   800.331.3397 Fax Conversion Materials


Under the provisions of your Group Long Term Disability (LTD) Insurance Coverage provided by Standard Insurance Company, you may have the right to convert your group LTD coverage. If you wish to apply for LTD Conversion Insurance, an application must be submitted, evidence of insurability may be required and if approved, your premiums must be paid within 31 days of the date of termination of your Group LTD Insurance Coverage. If you are interested in converting your Group LTD 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
My employment is terminated because I am unable to work due to sickness or injury? Yes NoToday's Date
 
Name
Birthdate
Group Name
Date your Group LTD Coverage ends:
Address:
City
State
Zip
Phone
Email Address
Please send application forms via:
E-mail Regular Mail

Section 'Sub' Navigation:

Page 'Breadcrumb' Navigation: