Long Term Disability Conversion Information Request Form

(Monthly Income Benefits)

  • Not all groups have this option: check your certificate.
  • Use this form when employee long term disability coverage (monthly income benefits) becomes eligible for conversion.
  • Check your certificate for the Conditions for Conversion. Residents of these states are NOT eligible for conversion: FL, IN, LA, MI, NY, OR, SD and WV.
  • Remember to complete the Employer's section of the form and attach a current Schedule of Benefits before distributing the form to the employee.
Form NameForm Number

LTD Conversion Information Request Form

43736f (115671)

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