Use this form when insured and/or dependent life coverage becomes eligible for conversion.
- Check the policy or certificate for the Conditions for Conversion.
- Remember to complete the Employer or Administrator section(s) before distributing the form to the insured person(s).
- 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 the policy or certificate for details.
- NOTE: This form must be provided each time life coverage becomes eligible for conversion, even if the insured person may also be eligible for other benefits under the policy.
|Form for Association Group Term Life and Individual TriTerm||Form Number |
|Form for Individual YRT||Form Number|
TBD - Contact your Account Representative
Employee Benefits insurance products and services in the U.S. are provided by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Woodbury, NY). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the ING family of companies. Product availability and specific provisions may vary by state. Each insurer is solely responsible for the financial obligations under the policies or contracts it issues.Ad Log #8625