Term Life Insurance Portability Request
This form is to be used only when a person desires and is eligible to portate Term Life Insurance. This form must be
completed in full and submitted to The Company within 31 days following the date of termination. SEND TO: Reliance
Standard Life Insurance Company, Premium Billing and Collection, 2001 Market Street, Suite 1500, Philadelphia, PA 19103-
7090.
VERIFICATION OF INSURED PERSON’S ELIGIBILITY TO PORTATE TERM LIFE INSURANCE
To Be Completed By Policyholder/Participating Unit
Male Female
1. Insured Person’s full name_________________________________ 2. Soc. Sec. Number_________________________
(Please Print)
3. Name of Policyholder/Participating Unit ________________________ 4. Policyholder/Participating Unit No.: _________
5. Branch or Location (if different from 3.) ________________________________________________________________
6. Date Employed: _____________ Salary: ____________ Date Last Salary Change: _____________ Class: __________
7. Effective Date of Coverage: Employee:_____________ Spouse, if any:_____________ Children, if any:____________
8. Occupation/Job Title ______________________________________9. Date Person Last Worked ________________
10.Date of Termination (if different from 9.) _______________________
11. If (9) and (10) differ, please explain _________________________________________________________________
12. Was the Insured’s Termination due to retirement? Yes No
13. Amount of Term Life Insurance (including the amount of any AD&D rider coverage, if applicable) in force under the Policy
on date of termination: Employee $_____________ Spouse, if any $_____________ Children, if any $___________
14.Verified by _______________________________________________________________________________________
(Signed by authorized individual) Date Phone Number
To Be Completed By Applicant
Name ______________________________________________________ Spouse’s Name _______________________
Address _________________________________________________________________________________________
(Street) (City) (State) (Zip)
Date of Birth: Employee: ________________Spouse, if any_______________ Children, if any____________________
Amount of Coverage Desired (must be equal to or less than amount in force):
Employee: $_________________________Spouse, if any: $_________________Children, if any: $_______________
Beneficiary:
Full Name(s) Relationship Percent of Proceeds SSN
_______________________ _________________________ ________________________ ______________________
_______________________ _________________________ ________________________ ______________________
_________________________________________________ ________________________ ______________________
Signature of Applicant Phone Number Date Signed
EF-1008-0806
