Insurance Life Portability Information

Insurance Life Portability Information

Purpose: This form documents the insured's election to exercise portability or conversion rights associated with an existing individual life insurance policy issued by the insurer named below. Completion of this form constitutes a written portability election, subject to the policy terms, any applicable group or employer plan rules, and the insurer's underwriting and administrative procedures.

Applicant / Insured Information

Insured Name:

Current Policy Details

Insurer Name:

Term Whole Life Universal Life Variable

Portability Election

I elect (select one or more as applicable):

Portability of existing coverage to a portability policy issued by the insurer

Conversion to an individual policy as permitted under the policy terms

Partial portability: Amount to port $

Coverage Options & Administration

Continued coverage requested for (check all applicable):

Base coverage Supplemental coverage Waiver of premium (if available)

Monthly Annual Payroll deduction (if applicable)

Exclusions, Conditions and Underwriting

The insurer's acceptance of this portability or conversion election is subject to the terms of the original policy and any group or portability plan provisions. The following conditions apply and are acknowledged by the applicant:

1. Portability or conversion is not effective until processed by the insurer and any required premium is received. The insurer reserves final authority to approve coverage and to require evidence of insurability. Any premium adjustments resulting from underwriting, age band changes, policy form differences or riders will take effect on the portability effective date or the insurer's administrative effective date, as applicable.

2. Portability does not reinstate or extend any coverage that was terminated for cause, for nonpayment beyond allowable grace periods, for material misrepresentation, or for any reason excluded under the policy. Certain riders and benefits may not be portable or may be subject to separate underwriting.

3. The applicant must provide truthful and complete answers to any questions posed by the insurer in connection with underwriting. Misstatements of material fact may result in rescission or adjustment of coverage to reflect premiums that would have been charged had the true facts been known.

Beneficiary Designation

Primary Beneficiary 1 Name:

Primary Beneficiary 2 Name:

Documentation Checklist

The following items must accompany this form where applicable. Check items enclosed:

Copy of current policy schedule / declarations

Evidence of insurability (medical questionnaire / forms)

Proof of identity (government ID or equivalent)

Employer authorization / termination confirmation (if required)

Declaration and Certification

By signing below, I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that the insurer may rely on the statements made herein in determining eligibility for portability or conversion and in setting premium rates. I authorize any medical practitioner, hospital, insurer or employer to release information about my health, employment or coverage history to the insurer for the purpose of evaluating this portability or conversion request. I acknowledge that any misrepresentation or omission of material facts may result in denial of coverage, rescission, or adjustment of benefits to reflect correct underwriting.

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