APPLICATION FOR CONVERSION OF
LONG TERM DISABILITY INSURANCE
Unum Life Insurance Company of America
PLEASE PRINT OR TYPE ALL INFORMATION
To Be Completed By The Employee
If you are currently disabled under the terms of your group policy, you should apply for disability beneﬁts not
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 Ofce. 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
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 benet 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
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 benets.
10.)Date at _____________________________________________________ on ___________________________________
City and State MM DD YYYY
Signature of Applicant __________________________________________________________________________________
Upon approval of this application, a certicate of coverage will be sent directly to you at the address provided.
Note: Employer MUST complete information required on reverse side.