GROUP LIFE CONVERSION APPLICATION
Reliance Standard Life Insurance Company
This form is to be used only when an eligible person desires to convert his Group Life insurance to an Individual policy. This form
must be completed in full and submitted to the Company within 31 days following the effective date of termination of insurance.
The top portion of this form is to be completed by the policyholder, the lower portion by the applicant. You may wish to refer to
your policy’s Schedule of Benefits page to complete some of the questions on this application.
When all areas are complete, mail to: Insurance Services
Division of Protective Life Insurance Company
Post Office Box 1268
7
Birmingham, AL 35202-6687
Fax: (205) 268-3402 Email: ladphs@protective.com
TO BE COMPLETED BY POLICYHOLDER
Name and Address of Group Policyholder and, if applicable, Division Name:
Policy No.: Policy Eff. Date:
Insured’s Full Name:
Male Female
Date of Birth:
Annual Salary/Earnings: $
Social Security No.:
Date Employment Began:
Occupation/Job Title:
Date Last Worked:
Scheduled Work Hours:
/week Insured’s Premium Paid To:
Insured’s: Effective Date:
Insurance Class: Insurance Amount: Basic $ Supp $
Reason Insured Stopped Work (specify):
Dependent Amt: $
Conversion Rights Exercised Due To (check applicable response):
_____ (1) Employee Terminated Employment On:
_____ (2) Group Policy Terminated On:
_____ (3) Disability of the Insured On: ________ Has A Waiver of Premium Claim Been Submitted to RSL? Yes___ No___
If No, Please Explain: ____________________________________________________________________________
_____ (4)Other, Please Explain: ___________________________________________________________________________
I have reviewed the information set forth, and represent that to the best of my knowledge and belief it is true and correct.
Signature Of Policyholder’s Authorized Representative Title Date Signed
(_____)__________________________________ ____________________________________________________
TO BE COMPLETED BY APPLICANT
I would like to convert $________________ of my group life insurance coverage that was in-force prior to the termination date.
Desired Mode of Premium Payment _____Quarterly _____Semi-Annually _____Annually
Beneficiary Designation
Upon the death of the insured, the proceeds of the policy to which this application is attached shall be paid as follows:
Primary Beneficiary(s)
Name________________________ Address____________________________ Relationship_________ Percentage________
Name________________________ Address____________________________ Relationship_________ Percentage________
Contingent Beneficiary(s)
Name________________________ Address____________________________ Relationship_________ Percentage________
Name________________________ Address____________________________ Relationship_________ Percentage________
If more than one primary beneficiary is named and no percentage is indicated, payment will be in equal shares to the surviving
primary beneficiary(s). If there are no surviving primary beneficiary(s), the proceeds will be paid to the contingent beneficiary(s).
If more than one contingent beneficiary is named and no percentage is indicated, payment will be in equal shares to the surviving
contingent beneficiary(s). If there are no surviving contingent beneficiary(s), the proceeds will be paid to the executors,
administrators, or assigns of the owner.
Applicant’s Address__________________________________________________________________________________
City, State, Zip Code_______________________________________________________ Phone (_____)_________________
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.
I have reviewed the information set forth above and represent that to the best of my knowledge and belief it is true and correct.
Signature____________________________________________________________ Date Signed______________________
LRS-1330-0299 FL
Phone Number of Representative Federal Employer Identification Number
