Group Life Portability Insurance Application

Group Life Portability Insurance Application

INSTRUCTIONS – PLEASE READ CAREFULLY

Portability Of Insurance

You may be eligible to buy portable Group Life Insurance if your employment with your employer terminates. If your employer’s Group Life Insurance plan includes Accidental Death and Dismemberment (AD&D) and/or Dependents Insurance, you may also be eligible to buy those coverages.

To be eligible, you must meet the following requirements:

1. You must have been continuously insured under your employer’s Group Life Insurance plan for at least 12 consecutive months on the date your employment terminates.

2. You must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience on the date your employment terminates.

3. You must be under age 65 on the date your employment terminates.

4. If you do not buy Life Insurance for yourself, you may not purchase any other insurance coverages.

The minimum and maximum amounts of insurance eligible for Portability Of Insurance are shown in your employer’s Group Life Insurance plan. The amounts of insurance you purchase under the Portability Of Insurance provision cannot be increased.

How to Apply

You must apply in writing and pay the first premium to us within 31 days after the date your employment terminates. This packet has two forms: one for you and one for your employer. You are responsible for making sure all required forms are completed and returned to our office.

Premium Computation Worksheet

GROUP ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE (if applicable)

Monthly Premium Rate is $0.04 per $1,000 of AD&D Insurance

a. Amount of Insurance from Line 3

b. Divide Line a by $1,000

c. Multiply Line b by $0.04 to arrive at Monthly Premium Amount $

Please type or print. COMPLETE ENTIRE FORM.

1. MEMBER INFORMATION

Name (last, first, middle)

Sex Male Female

Street address City State Zip code

Social Security No. Telephone Birthdate

2. DEPENDENTS INFORMATION (if applicable)

Spouse name (last, first, middle) Spouse birthdate

3. EMPLOYER INFORMATION

Name of group Group Number

Name of employer (if different) Employer HR Contact and Phone Number

Your occupation with the employer

Date you last worked for the employer Employment termination date (if different)

If date you last worked and employment termination date differ, please explain:

4. ELIGIBILITY

Date you became insured under your Employer’s coverage under the Group Policy

Have you been insured under your Employer’s group life insurance plan for at least 12 consecutive months? Yes No

Is your employment terminating due to medical reasons? Yes No

Are you able to perform with reasonable continuity the material duties of at least one gainful occupation for which you are reasonably fitted by education, training and experience? Yes No

Are you under the age of 65 on the date your employment terminates? Yes No

Have you or your spouse used tobacco in any form in the last 12 months? Member: Yes No Spouse: Yes No

5. AMOUNT OF INSURANCE COVERAGE REQUESTED

GROUP LIFE and, if applicable, DEPENDENTS LIFE INSURANCE

Member AD&D

Spouse AD&D

Children AD&D

6. BENEFICIARY

This beneficiary designation applies to all of your Group Life Portability Insurance and Accidental Death and Dismemberment Insurance, if any.

Primary

Contingent

7. AGREEMENT

I hereby apply for Group Life Portability Insurance.

I agree that no coverage will take effect until it is approved in writing by Standard Insurance Company. I understand that if my request is not accepted, any premium advanced by me will be refunded.

I understand that if I do not designate a beneficiary in the Beneficiary section on the preceding page, payment of any benefit will be made in accordance with the Benefit Payment and Beneficiary Provisions of the Group Life Portability Insurance Policy.

I hereby represent that all statements contained herein are complete and true to the best of my knowledge and belief, and that I meet all eligibility requirements. I have read and understand the information herein, including the applicable Fraud Notice below.

Signature

EMPLOYER STATEMENT FOR GROUP LIFE PORTABILITY INSURANCE

1. MEMBER INFORMATION

Full name Sex Male Female

Social Security No. Birthdate Occupation

Member’s Insurance Class, if any, as defined by the Group Policy

2. EMPLOYER INFORMATION

Group name Employer name (if different)

Group number Effective date of Employer’s coverage under the Group Policy with The Standard

Is the Member’s Group Life Insurance terminating because employment is ending? Yes No

If yes, date employment ended Date coverage ends

Date Member last worked

If no, reason for termination of Member’s Group Life Insurance

Is employment terminating due to medical reasons? Yes No

Original effective date of Member’s coverage as your Employee (including with your prior carrier)

3. AMOUNT OF INSURANCE

GROUP LIFE and, if applicable, DEPENDENTS LIFE INSURANCE

Member Basic Additional (if applicable) AD&D Insurance

Spouse AD&D Insurance

Children AD&D Insurance

4. ANNUAL EARNINGS

Annual earnings on the last day of active work

Date of the last pay increase/decrease

Annual earnings prior to the last pay increase/decrease

5. EMPLOYER AUTHORIZATION

I hereby represent that the above information is true and complete to the best of my knowledge. In addition, I acknowledge I have read the Fraud Notice on the next page.

Name and title (please print or type)

Address Direct telephone number

6. ATTACHMENTS

PLEASE ATTACH COPIES OF ALL LIFE ENROLLMENT FORMS

Note: If enrollment forms are not provided, it may prevent us from approving the application.

FRAUD NOTICES

FOR RESIDENTS OF ARKANSAS, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO, OKLAHOMA, TENNESSEE AND WASHINGTON: Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed.

FOR RESIDENTS OF COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages.

FOR RESIDENTS OF FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree.

FOR RESIDENTS OF MARYLAND AND RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FOR RESIDENTS OF PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.