Insurance Conversion Policy

INSURANCE CONVERSION POLICY

Applicant / Insured Information

Original Policy / Group Information

Original Insurer:

Original Policy Number:

Group or Employer (if applicable):

Conversion Request & Effective Dates

Conversion Requested On:

Requested Conversion Effective Date:

Conversion Must Be Completed By (Deadline):

Converted Policy Details

Assigned Converted Policy Number (by insurer):

Whole Life

Universal Life

Term to Permanent Conversion

Other:

Premium Payment Due Date Each Period:

Accidental Death — Continued

Waiver of Premium — Continued

Accelerated Benefit — Continued

Other Riders:

Proof of Insurability / Underwriting

Evidence of Insurability Required: Yes No

If evidence required, specify documents:

If evidence waived, reason/authority:

Exclusions and Limitations

The converted policy shall be issued subject to the insurer's standard exclusions and the following specific limitations (acknowledge applicable items):

Loss due to declared or undeclared war, whether or not serving in the armed forces

Death or injury resulting from intentionally self-inflicted injury or attempted suicide within 24 months of policy effective date

Loss sustained while committing or attempting to commit a felony

Coverage voidable for material misstatement on conversion application or prior policy application

Beneficiary Designation

Primary Beneficiary 1 Name:

Contingent Beneficiary Name:

Declarations, Representations & Authorizations

By signing below, Applicant certifies that all statements made in connection with this conversion request and any accompanying application are true and complete to the best of Applicant's knowledge. Applicant acknowledges that any material misrepresentation may render coverage voidable pursuant to the terms of the converted policy.

Applicant further understands and agrees that: the converted policy shall be issued subject to the insurer's terms, conditions, exclusions and waiting periods; the insurer's acceptance of this conversion request may require evidence of insurability where indicated above; and premium rates for the converted policy will be determined in accordance with the insurer's rate schedules and the age of the insured on the effective date of conversion.

Applicant authorizes the release of medical and other records to the insurer for the purpose of underwriting or claims handling and acknowledges receipt of any required written notice relating to conversion rights under the original policy.

I acknowledge receipt of the terms of conversion and understand the resulting policy provisions, exclusions and premium obligations.

Claims & Post-Issuance Matters

Claims for benefits under the converted policy shall be submitted in accordance with the policy terms and submitted to the insurer at the address provided in the policy. Proofs of loss, medical records and other supporting documentation shall be furnished as required by the policy.

Signature and Certification

By signing below, Applicant certifies under penalty of perjury that the information provided on this form is true and complete and that Applicant is authorized to request the conversion. Applicant acknowledges that issuance of the converted policy is subject to insurer acceptance and the terms contained herein.

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