Fillable Instructions for Use Application to Convert Group Life (University of Texas System)

Fill Online, Printable, Fillable, Blank Instructions for Use Application to Convert Group Life (University of Texas System) Form

Use Fill to complete blank online UNIVERSITY OF TEXAS SYSTEM pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Instructions for Use Application to Convert Group Life (University of Texas System)

On average this form takes 19 minutes to complete

The Instructions for Use Application to Convert Group Life (University of Texas System) form is 3 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your University of Texas System forms online.

BROWSE UNIVERSITY OF TEXAS SYSTEM FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Mail to Dearborn Life Insurance Company at:
Attn: Department 6006
P.O. Box 7070
Downers Grove, IL 60515
Application to Convert Group Life Insurance
Phone Number: (866) 628-2606
Page 1 of 5
R040119 | Z5254_BCBSTX
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.
Instructions for Use
The application to convert group life insurance is to be utilized when you become ineligible for group insurance. An
example of this would be termination of employment. The application is used to convert your Group Life Insurance
coverage to an Individual Whole Life Insurance policy. This can be done regardless of your current health. For
information about the amount you may convert or how long you have to convert, see either your certificate or group
policy. The application must be filled out by both your employer and yourself.
Part 1 - To be filled out by the Employer
• Ensure the Amount of insurance is filled out for each applicable product (Basic Life, Supplemental Life, Voluntary
Life, etc) eligible for conversion.
• Specify clearly the reason for termination.
• If an error is made, you may strike the error, but you must initial the change.
Part 2 - To be filled out by the Insured/Applicant
• If electing Electronic Funds Transfer (EFT) please ensure that you sign the authorization on the second page of
the application and attach a voided check.
• If an error is made, you may strike the error, but you must initial the change.
• If applicant is under the age of 20, please contact customer service for applicable rate.
R040119 | Z5254_BCBSTX
Mail to Dearborn Life Insurance Company at:
Attn: Department 6006
P.O. Box 7070
Downers Grove, IL 60515
Application to Convert Group Life Insurance
Phone Number: (866) 628-2606
FDL5-4-412
Page 2 of 5
Dearborn Life Insurance Company
Upon becoming ineligible for group insurance, e.g., leaving employment, you may convert your Group Life Insurance coverage to
an Individual Whole Life Insurance policy. This can be done regardless of your current health. For information about the amount
you may convert or how long you have to convert, see either your certificate or group policy.
To apply:
1. Complete Part 2 of this conversion application. Be sure your Employer has completed Part 1. Premium rates and instructions
are shown on the reverse side.
2. Mail the completed application with your check or money order for the first modal premium to the above address.
Part 1: TO BE COMPLETED BY EMPLOYER
Group Number
Date Employment Term'd Date Coverage Terminated Last Actual Day of Work Amount of Group Insurance
Name of Employer Providing Group Policy Annual Salary Insurance Class
Signature of Policyholder's Representative/Title Telephone Number Date Signed
Reason for Termination
Other (Specify)
Disability
Termination of Group Policy and
Termination of employment or
membership in eligible class
Date Term'd
Part 2: TO BE COMPLETED BY INSURED Please type or print with ball point pen
I hereby apply to convert my life insurance and affirm the following statements of fact:
NAME IN FULL SOCIAL SECURITY NUMBER TELEPHONE NUMBER GROUP POLICY NO.
RESIDENT ADDRESS
STREET CITY STATE ZIP CODE
SEX DATE OF BIRTH AGE LAST BIRTHDAY STATE OF BIRTH LAST DATE OF ACTIVE WORK PRESENT OCCUPATION
AMOUNT OF INSURANCE
TO BE CONVERTED
PREMIUM MODE
Annual
EFT Monthly*
Quarterly
Semi-Annual
First full modal premium must be submitted
with application
Premium Enclosed $
Yes No
Automatic Premium Loan
Provision Desired?
BENEFICIARY DESIGNATION
Primary
FIRST NAME LAST NAME ADDRESS SOCIAL SECURITY NO DATE OF BIRTH RELATIONSHIP
Secondary
FIRST NAME LAST NAME ADDRESS SOCIAL SECURITY NO DATE OF BIRTH RELATIONSHIP
If more space is need 1) use extra paper 2) mark able "See Attached" 3) attachment MUST be signed and dated by Policy Owner.
Is the owner to be other than the insured?
Yes No
FIRST NAME INITIAL LAST NAME RELATIONSHIP
Address of Owner, if other than Insured:
No. & Street City State Zip Code
The Owner is the person who may exercise all rights in the contract, e.g., assign, surrender, borrow. If no one is named, the Insured shall be the Owner.
I declare that the information on this application is complete and true, to the best of my knowledge and belief. I agree that the Company may
deposit the payment submitted with this application prior to approval of this application. If I am not eligible to convert my Group Insurance, the
sole obligation of the Company shall be to refund any premiums paid.
Signed At
City State
on
Mo Day Year Signature of Applicant
*EFT (Electronic Funds Transfer - Sign on back and attach voided check)
Signature of Owner (Other than Insured)
R040119 | Z5254_BCBSTX
FDL5-4-412
Premium Calculation Worksheet
For Conversion from Group Life to Individual Whole Life Policy
Page 3 of 5
Dearborn Life Insurance Company
Premiums are payable to age 98 or death, whichever occurs first. For information about the amount you are eligible to convert,
please refer to the Conversion of Life Insurance provision of your group life insurance certificate or the group policy. Our minimum
issue amount is $2,000.
To calculate your premium, find your present age and the corresponding table rate per $1,000 from the columns below. Multiply
this premium by the number of thousands of dollars of insurance you plan to convert. Then multiply by the premium factor and
add the modal policy fee to find your premium payment.
Last
Birthday
Table Rate
Per Thousand
Last
Birthday
Table Rate
Per Thousand
20.....................6.51 60...................47.79
21.....................6.86 61...................50.70
22.....................7.09 62...................53.72
23.....................7.42 63...................56.86
24.....................7.76 64...................60.23
25.....................8.10 65...................63.84
26.....................8.56 66...................67.67
27.....................8.90 67...................71.74
28.....................9.22 68...................76.05
29.....................9.68 69...................80.47
30...................10.13 70...................85.24
31...................10.58 71...................90.70
32...................11.03 72...................96.55
33...................11.59 73.................102.77
34...................12.14 74.................109.38
35...................12.70 75.................116.41
36...................13.25 76.................123.90
37...................13.92 77.................131.94
38...................14.58 78.................140.61
39...................15.23 79.................150.02
40...................15.89 80.................160.20
41...................16.77 81.................171.21
42...................17.76 82.................183.01
43...................18.73 83.................195.57
44...................19.71 84.................208.90
45...................20.79 85.................223.10
46...................21.97 86.................282.86
47...................23.14 87.................342.62
48...................24.53 88.................402.38
49...................25.90 89.................462.15
50...................27.36 90.................521.91
51.........
..........28.92 91.................581.67
52...................30.56 92.................641.43
53...................32.28 93.................701.19
54...................34.10 94.................760.95
55...................36.10 95.................820.72
56...................38.10 96.................880.48
57...................40.30 97.................940.24
58...................42.68 98..............1,000.00
59...................45.16
( √ )
Mode Desired Premium Factor Modal Policy Fee
Annual........................... 1.000 .....................$17.00
Semi-Annual.................... .520 .....................$9.00
Quarterly.............. ........... .265 .....................$5.00
EFT Monthly................ .08583 .....................$0.00
(Sign below & attach voided check)
Enclose the Modal Premium amount
with your application.
For clarification, contact
DEARBORN LIFE INSURANCE COMPANY
Attn: Department 6006
1020 31st Street
Downers Grove, IL 60515
1-866-628-2606
EFT Authorization: Check one:
Checking Savings
Account #
I hereby authorize and request Dearborn Life Insurance Company
to withdraw funds from my account and transfer those funds in
payment for my monthly premium, and to initiate debit entries, if
necessary, for any credit entries made in error. This authorization
is to remain in full force until I notify Dearborn Life Insurance
Company in writing of any changes or cancellation of payment. I
understand that to change or cancel any future transactions, such
notice must be received not less than ten business days prior to
the transaction date.
Signature of Account Holder
(Please attach voided check)
Example: Conversion of $10,000 Group Life for a 45-year old to $10,000 Whole Life Plan payable quarterly:
Example:
Table Rate X # of Thousands To Be Converted X Premium Factor + Modal Policy Fee = Modal Premium
20.79 X 10.000 X 0.265 + 5.00 = 60.10
Your Calculations:
Table Rate X # of Thousands To Be Converted X Premium Factor + Modal Policy Fee = Modal Premium
$
R040119 | Z6291_LC_BCBSTX
Page 4 of 5
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.
Administrative Office: 701 E. 22nd Street, Lombard, Illinois 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
Maryland: Any person who knowingly or willingly presents a
false or fraudulent claim for payment of a loss or benefit or
who knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Virginia: Any person who, with the intent to defraud or
knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or
deceptive statement may have violated the state law.
FOR APPLICATIONS AND CLAIMS:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading material facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company
who knowingly provides false, incomplete, or misleading
material facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of
regulatory agencies.
District of Columbia: WARNING: It is a crime to provide
false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties
include imprisonment and/or fines. In addition, an insurer
may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or a statement of claim containing
any materially false information or conceals, for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Louisiana: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement
in prison.
Maine & Washington: It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance
benefits.
New Mexico: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to civil
fines and criminal penalties.
Ohio: Any person who, with intent to defraud or knowing
that he is facilitating a fraud against an insurer, submits
an application or files a claim containing a false or
deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim for
the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and
civil penalties.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a
loss or any other benefit, or presents more than one claim
for the same damage or loss, shall incur a felony and,
upon conviction, shall be sanctioned for each violation
with the penalty of a fine of not less than five thousand
dollars($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3)
years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years, if
extenuating circumstances are present, it may be reduced
to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Alabama: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application
for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any
combination thereof.
R040119 | Z6291_LC_BCBSTX
Page 5 of 5
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.
Administrative Office: 701 E. 22nd Street, Lombard, Illinois 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Idaho: Any person who knowingly, and with intent
to defraud or deceive any insurance company,
files a statement or claim containing false,
incomplete, or misleading information is guilty of a
felony.
Alaska: A person who knowingly and with intent
to injure, defraud, or deceive an insurance
company files a claim containing false,
incomplete, or misleading information may be
prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on this
form. Any person who knowingly presents a false
or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
Arkansas: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in
an application for insurance is guilty of a crime
and may be subject to fines and confinement in
prison.
California: For your protection California law
requires the following to appear on this form. Any
person who knowingly presents false or fraudulent
claim for the payment of a loss is guilty of a crime
and may be subject to fines and confinement in
state prison.
Delaware: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer,
files a statement of claim containing any false,
incomplete or misleading information is guilty of a
felony.
Indiana: A person who knowingly and with intent
to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading
information commits a felony.
Minnesota: A person who files a claim with intent to
defraud or helps commit a fraud against an insurer
is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files a
statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Texas: Any person who knowingly presents a
false or fraudulent claim for the payment of a
loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Massachusetts: Any person who knowingly
presents a false or fraudulent claim for
payment of a loss or benefit or knowingly
presents false information in an application for
insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FOR APPLICATIONS ONLY:
New Jersey: Any person who includes any
false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Instructions for Use Application to Convert Group Life (University of Texas System)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document