Life Conversion Information Request Form

  • Use this form when employee and/or dependent life coverage becomes eligible for conversion.
  • Check your certificate for the Conditions for Conversion.
  • Remember to complete the Employer's section before distributing the form to the insured person(s).
  • If ownership of employee 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: 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 NameForm Number

Life Conversion Information Request Form for group policies issued by ReliaStar Life Insurance Company (with brochure 151671 attached)

147077 (11/25/2013)

Minnesota Term Life Conversion Information Request Form for MN employees at end of 18 month MN Continuation period

151852 (11/16/2011)

Life Conversion Information Request Form for group policies issued by ReliaStar Life Insurance Company of New York (with brochure 152056 attached)

147455 (11/25/2013)

Ad Log #8619