Fillable GROUP LTD CONVERSION FACTS Unum Life Insurance Company (Youngstown State University)

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GROUP LTD CONVERSION FACTS Unum Life Insurance Company (Youngstown State University)

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Eligibility:
If you have been covered for Long Term Disability benets under a group LTD plan sponsored by your employer for
at least 12 consecutive months* and your employment terminates while insured with Unum Life Insurance Company
of America (Unum), you may be eligible to convert and become insured under the Unum Group Long Term Disability
Conversion Policy.
*These twelve (12) consecutive months include the time you were insured for group long term disability under both
this policy and the former policy it replaced, if any.
To be eligible to convert, your coverage must have ceased due to termination of your employment. If you become
insured under another group plan within 31 days after termination and have already applied for conversion coverage
you are required to notify Unum.
You will be eligible for insurance on the day your coverage terminates under the group plan.
Some Reasons Why You Cannot Convert:
The conversion privilege is not available to you if:
1. your insurance under the group plan terminates for any of the following reasons:
a. the group plan terminates;
b. the group plan is amended to exclude from coverage the class of employees to which you belong;
c. you no longer belong to a class of employees eligible for coverage under the group plan;
d. you retire. (You retire when you receive payment from the employer’s retirement plan as recognition of
past services, OR you have concluded your working career.)
2. you are or become insured for long term disability insurance under another group insurance plan within 31
days after termination.
3. you failed to pay any required premium due.
4. you are disabled under the terms of the group plan.
5. you recover from a disability and you do not return to work for this employer.
6. you are on a leave of absence.
Monthly Benefits:
Your monthly benet will be 60% of your last basic monthly earnings with this employer, up to a maximum of $4,000
(standard) or $6,000 (with evidence of insurability).
If the benet percentage and maximum monthly benet under the former plan are less than the above gures, the
participant’s coverage under this conversion policy will be equal to the former plan’s benet percentage and maximum
monthly benet.
GROUP LTD CONVERSION FACTS
Unum Life Insurance Company of America
276-89 (05/11)
Premium Rates for LTD Conversion Coverage:
Quarterly rates per $100 of Monthly Benet
Age Quarterly Rate
Less than 25 $ 1.67
25-29 2.52
30-34 3.87
35-39 5.97
40-44 7.32
45-49 10.80
50-54 17.15
55-59 21.14
60 and over 21.27
Plus a one time non-refundable Application Fee: $25.00.
How to Calculate Your Premium:
Example: Quarterly premium for an individual age 30 with basic monthly earnings of $2,000:
60% of $2,000 = $1,200; 1,200 ÷ 100 = 12; 12 x $3.87 = $46.44.
Quarterly mode is the only premium frequency available. Rates are not guaranteed and may be changed at any time
with a 31-day notice.
Premium Worksheet:
A. Current Age _____________
B. Quarterly Rate (from premium rate chart, based on your age) _____________
C. Your last basic monthly earnings (see #17 on the Conversion Application) under the group plan before termination
$____________
D. Take 60%* of the last basic monthly earnings $_____________. If this dollar amount exceeds $4,000**, your benet
amount will be limited to $4,000**. Insert $4,000.
You may apply for a $6,000 benet limit by submitting the Evidence of Insurability Application from your employer.
If you apply and are approved, your premium will be adjusted on your next bill.
E. Divide D by 100 = $_____________
F. Multiply E by B = $_____________ (This equals your quarterly premium amount.)
When applying for Conversion, please remit the amount in F, plus the $25.00 non-refundable Application Fee.
* If your group plan’s benet percentage was less than 60%, use the same benet percentage as the group plan.
** If your group plan’s maximum monthly benet was less than $4,000, use the same maximum monthly benet as the
group plan.
If you have any questions, you may contact your Unum Sales Ofce, or call our Customer Services Call Center in
Portland, Maine at 1-800-421-0344.
PLEASE NOTE: THIS IS NOT A CONTRACT OF INSURANCE
ONCE APPROVED, COMPLETE DETAILS OF COVERAGE INCLUDING EXCLUSIONS, LIMITATIONS AND
BENEFIT REDUCTIONS WILL BE EXPLAINED IN YOUR LONG TERM DISABILITY BENEFITS CONVERSION
CERTIFICATE. YOU MUST REVIEW YOUR CERTIFICATE CAREFULLY WHEN YOU RECEIVE IT.
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
276-89 (05/11)
APPLICATION FOR CONVERSION OF
LONG TERM DISABILITY INSURANCE
Unum Life Insurance Company of America
Portland, Maine
PLEASE PRINT OR TYPE ALL INFORMATION
To Be Completed By The Employee
n
If you are currently disabled under the terms of your group policy, you should apply for disability benefits not
conversion.
■
To apply for this coverage you must submit this completed application, the $25.00 application fee and your rst quarterly pre-
mium to Unum’s Home Ofce. The mailing address is:
Unum Portability/Conversion Unit, 2211 Congress Street, Portland, Maine 04122
■
The application must be received by Unum Life Insurance Company of America (Unum) within 31 days after termination of
coverage.
■
If you become eligible for or covered under any other Group Long Term Disability policy within the 31-day period in which you
must apply for this Conversion Privilege, you cannot convert to this coverage.
1.) Name (Last, First, Middle Initial) 2.) Sex 3.) Social Security Number
l M l  F
4.) Home Address (Street, City, State, Zip) 5.) Phone Number
6.) Email Address 7.) Date of Birth (mm/dd/yyyy)
8.) Group LTD Plan Number ____________________________
9.) Check the maximum monthly benet you are applying for:
(See your Conversion Facts for further explanation.)
■ a. Standard Option = $4,000
■ b. Higher Maximum Option = $6,000
Option b is only available upon completion of an Application and Evidence of Insurability form and acceptance by the insurance
company.
Note: If the maximum monthly benefit amount under the group plan from which you are converting is less than the
above, then you will convert to that lesser amount.
The statements above are true to the best of my knowledge and belief, and I agree that they shall form a part of the contract
of insurance applied for.
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, nes or a denial of insurance benets.
10.)Date at _____________________________________________________ on ___________________________________
City and State MM DD YYYY
Signature of Applicant __________________________________________________________________________________
Upon approval of this application, a certicate of coverage will be sent directly to you at the address provided.
Note: Employer MUST complete information required on reverse side.
AE-1119 (02/10)
To Be Completed By Employer
11.) Employer (Firm Name and Division)
12.) Group LTD Plan Benet %
13.) Group LTD Plan Maximum Benet
14.) Was the individual covered under your present Group Plan or under a combination of your present and prior Group Plans for
at least 12 consecutive months? ■ Yes ■ No
If No, the employee is not eligible for coverage under the terms of the contract.
If yes, the individual’s effective date (mm/dd/yyyy):
15.) Is employee’s group coverage ending as a result of retirement, leave of absence or disability? ■ Yes ■ No
If yes, the employee is not eligible for coverage under the terms of the contract.
16.) Date employee terminated employment: (The conversion coverage must be applied for and the rst quarterly premium paid
within 31 days of this date (mm/dd/yyyy).)
17.) Employee’s basic monthly earnings at time of termination
$_____________________
18.) Employee’s Occupation at time of termination
19.) Reason for Employee termination
20.) Employer Representative Signature Date (mm/dd/yyyy)
This Section is not a part of the application for conversion.
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, nes or a denial of insurance benets.
Note: Employee must complete the application on the reverse side.
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
AE-1119 (02/10)
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GROUP LTD CONVERSION FACTS Unum Life Insurance Company (Youngstown State University)

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Completed 2 February 2021

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