Term Life Coverage Continuation Request Form

  • This is used ONLY for groups that have the optional portability benefit for life coverage. Check your certificate for details before distributing this form.
  • Remember to complete the Employer sections of the form before distributing the form to the insured person.
  • If ownership of coverage is assigned, the form must be distributed to the owner instead of to the insured person.
  • NOTE: There are time limits that pertain to your distribution of this form and the recipient's return of the completed form to the insurance company. See your certificate for details.
  • NOTE: The owner of coverage must also receive the Conversion Information Request Form along with this form.
Form NameForm Number

Term Life Coverage Continuation Request form for group policies issued by ReliaStar Life Insurance Company

44316g (115717)

Supplemental Life Coverage Continuation Request form for group policies issued in New York by ReliaStar Life Insurance Company of New York

124104

Ad Log #8619