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Conversion PA (Wilkes University)

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Life Conversion Coverage
Life Goes on with Group Conversion
Your group life insurance has been valuable protection for you and your family. Now that it will be terminated, you may
wish to convert this important coverage to an individual policy. This information has been prepared to help you take
advantage of your right to continue your protection.
About Life Conversion Coverage
Life Conversion Coverage is individual permanent life insurance issued without evidence of insurability.
Life Conversion Coverage can be obtained when your life insurance under the group policy ends. Your group certificate
will describe when conversion coverage is available to you, and will show the amount of coverage you can convert.
Conversion coverage will be issued without evidence of good health, provided:
(a) you complete the attached application,
(b) you enclose a check or money order for the first premium payment and
(c) these items are forwarded to us within 31 days after your group insurance ends.
Your conversion policy will be effective on the 31st day after your group insurance ends. During this 31-day period, you
remain covered under the continued coverage provision of your group certificate.
You may apply for an amount that is not more than the amount of your current group insurance coverage (this is your
maximum). You may elect coverage in $1,000 increments up to your maximum.
The individual policy is Whole Life Express Insurance, which provides a level benefit throughout your lifetime. Premiums
for this coverage are payable while living until the policy anniversary following age 100.
Premium rates are shown in the table that follows. If premium payments are discontinued, you may:
(a) receive any existing cash value or
(b) use the cash value to purchase extended term insurance or a reduced amount of paid-up life insurance.
For additional information or premium rates on conversion coverage, please write or call us at:
Attn: Group Policy Services, Group Conversion
United of Omaha Life Insurance Company
Mutual of Omaha Plaza
Omaha, Nebraska 68175
Phone: 1-800-826-8054
To Apply for Life Conversion Coverage
In order to apply for life conversion coverage, you must do the following:
1) Complete the Life Conversion Application that follows. Use black or blue ink, or a typewriter. Write clearly and do not
erase – any corrections should be crossed out and initialed by you. Answer each question fully – do not use dashes or
ditto marks.
2) Make sure the section entitled “Information to be Completed by the Personnel Office” is completed by the employer or
administrator of the group policy.
3) Attach your check or money order payable to United of Omaha Life Insurance Company for the first annual or
semiannual premium payment.
4) Send your premium payment and completed application to the above address within 31 days after your group
insurance ends.
Privacy Notice: When United of Omaha Life Insurance Company evaluates an application for life conversion coverage, only the information
on the application is reviewed. This information, and other information we may later collect to administer coverage, may sometimes be
disclosed without your express authorization. We have a procedure which allows you to review and amend any information we collect about
you – other than information relating to a claim, lawsuit or criminal proceeding. If you would like to know more about our information
practices, please write us at the address shown above.
MUGC9173_0816
Calculating The Premium
The premium amounts in the table below are per $1,000 of coverage. Calculate your annual and/or semiannual premium
in the calculation worksheet, following the steps and example below.
To calculate annual and semiannual premium:
1) Divide your desired death benefit amount by 1,000.
2) Locate your age group and gender on the table below to identify the premium rate per thousand.
3) Multiply #1 by #2 above.
4) Add $36 for the annual policy fee to obtain the annual premium for the coverage.
5) Multiply the annual premium by .52 to obtain the semiannual premium for the coverage.
Issue Age Male Female
0-4 $6.80 $6.10
5-9 $7.70 $6.90
10-14 $8.80 $7.80
15-19 $10.00 $9.00
20-24 $17.00 $12.50
25-29 $21.00 $15.00
30-34 $25.00 $17.50
35-39 $30.00 $20.50
40-44 $35.00 $24.00
45-49 $41.00 $30.00
50-54 $46.00 $33.00
55-59 $58.00 $40.00
60-64 $80.00 $51.00
65-69 $111.00 $72.00
70-74 $154.00 $108.00
75-79 $196.00 $149.00
80-84 $238.00 $198.00
85 $304.00 $255.00
Example (Assumes a 50-year-old male with current group life coverage of $20,000.)
20 x $46.00 = $920.00 + $36 = $956.00
____________________ ___________________ ______________ ______________ _______________
Desired coverage amount/$1,000 Premium rate per thousand Premium for coverage Annual policy fee Total annual premium
$956.00 x .52 = $497.12
____________________ ___________________
Total annual premium Total semiannual premium
Calculation Worksheet
x = + $36 = $
____________________ ___________________ ______________ ______________ _______________
Desired coverage amount/$1,000 Premium rate per thousand Premium for coverage Annual policy fee Total annual premium
x .52 =
____________________ ___________________
Total annual premium Total semiannual premium
Conversion Application
This application must be completed and mailed within 31 days after your group insurance ends. Mail the conversion to:
Attn: Group Policy Services, Group Conversion, United of Omaha Life Insurance Company, Mutual of Omaha Plaza,
Nebraska 68175.
Life Insurance Section
1 Applicant’s Name (First, Middle, Last)
________________________________________________
2 Social Security Number
________________________________________________
3 Male
n Female n
4 Age _______ 5 Date of Birth _____ _____ _____
Mo. Day Yr.
6 Residence (Number, Street, City, State, ZIP)
________________________________________________
________________________________________________
11 Beneficiary (Give full name and relationship to applicant)
Primary ______________________________________________________________________________________
Contingent ____________________________________________________________________________________
Payment will be shared equally by all primary beneficiaries who survive you; if none, it will be shared equally by all
contingent beneficiaries who survive you. Unless otherwise stated, you have the right to change the beneficiary.
Group Information Section
1 Group Policyholder _____________________________________________ Group Policy No.__________________
2 I have been insured under the above Group Policy as:
n An employee or member n A dependent
3 I became insured under the Group Policy: __________ Month __________ Day __________ Year
4 My group insurance terminated: __________ Month __________ Day __________ Year
5 Was termination due to disability?
n Yes n No
(If “Yes,” give date and cause of disability.) ____________________________________________________________
Life Agreements Section
I am applying to United of Omaha for the life conversion coverage shown above. I agree United will not be under any
obligation or liability under this application unless:
(1) I have the right to convert the insurance shown above.
(2) The application is made within 31 days after my group insurance ends.
Date ___________________________ , ________ State signed in ___________________________________________
______________________________________________
Applicant’s Signature
Whole Life Express Policy Form 6879L-0202, or state equivalent. In OK, 6918L-0202. In OR, 6949L-0202. In TX, 6920L-0202.
135L-0682
7 Home Phone Number (______)______________
8 Amount of Insurance $_____________________
(Show amount in thousands, not greater than the
amount you are entitled to convert.)
9 Mode of Premium Payments
n Annually n Semiannually
10 Amount Paid with Application
$ _______________________
Information to be completed by the personnel office
Group Policyholder ________________________________________________________________________________
Policy No. ___________________________________________ Phone (__________) ___________________________
Address (Number, Street, City, State, ZIP) _______________________________________________________________
Applicant’s Name __________________________________________________________________________________
Certificate No. ____________________________________________________________________________________
1 The Applicant was insured under the above Group Policy as:
n An employee or member n A dependent
2 For what amount of coverage was the Applicant insured? $ ___________
3 What is the Applicant’s date of birth? _________ Month _________ Day _________ Year
4 When did the Applicant become insured under the Group Policy? _________ Month _________ Day _________ Year
5 The Applicant’s coverage was:
n terminated on _________ Month _________ Day _________ Year
n reduced by $ __________ on _________ Month _________ Day _________ Year
Because of ________________________________________________________________________________________
_________________________________________________________________________________________________
Completed by _____________________________________________________ Signature (Employer or Administrator)
Title ____________________________________________________________ Date ________________ , __________
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Completed 23 July 2020

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