Fillable Standard Insurance Company GROUP LIFE INSURANCE PORTABILITY FORM

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Standard Insurance Company GROUP LIFE INSURANCE PORTABILITY FORM

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31 Days TGP
SI 305-8199 PKT
Page 1 of 5 (12/17)
Standard Insurance Company GROUP LIFE INSURANCE
PORTABILITY FORM
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
INSTRUCTIONS - PLEASE READ CAREFULLY
Portability Of Insurance
You may continue your Life Insurance and other insurance eligible for portability as shown in the Coverage Features section
of your Certicate, subject to the following:
1. The amount of any Insurance to be continued must have been continuously in effect for at least 12 consecutive months
on the date your employment terminates.
2. You must be able to perform with reasonable continuity the material duties of at least one gainful occupation for which
you are reasonably tted by education, training and experience on the date your employment terminates.
3. Termination of your employment is not due to your retirement.
4. If you do not continue your Life Insurance, you may not continue any other Insurance.
The minimum and maximum amounts of Insurance eligible for Portability Of Insurance are shown in the Coverage Features
section of your Certicate. The amounts of Insurance you continue cannot be increased. Insurance amounts will be reduced
or terminated according to the terms of the Group Policy in effect on the date your employment terminates.
NOTE: Refer to Right To Convert in your Certicate for information regarding eligibility to convert to an individual life insurance
policy. Any combination of Insurance you continue and Insurance you convert may not exceed the amount for which you or
your Dependents were insured on the date your employment terminates.
How To Apply
You must apply in writing and pay the rst premium to us within 31 days after the date your employment terminates. This packet
has two forms: one for you and one for the Policyholder/Employer. All questions on these forms must be completed. If you
have questions, please contact our office at the phone number shown above. You are responsible for making sure all required
forms are completed and returned to our office. Processing will begin when both completed forms are received by us.
Premium rates are shown in the Coverage Features section of your Certicate, and are subject to increase with advancing
age. Premium rates may be changed by Standard with advance written notice. If approved, you will be billed quarterly (every
three months), at your home address. Premium must be received by the due date. There is no grace period for Portability Of
Insurance. Checks are to be payable to Standard Insurance Company.
Keep your Certicate. It is your certicate of coverage for your continued insurance under the Portability Of Insurance provision.
Please note that Insurance continued under the Portability Of Insurance provision ends automatically on the earliest of:
1. The date it would otherwise end under the Group Policy.
2. The date you become insured under any other group life insurance plan.
3. For any Dependent, the date you insure the Dependent under any other group life insurance plan, or who ceases to be a
Dependent according to the terms of the Group Policy.
Beneciary Designation
Please provide us with the beneciary designation form on le with the Policyholder/Employer. If you cannot provide that
form, or if you wish to change your beneciary designation, please complete the Beneciary section on Page 3. If we do not
receive the form and if you do not complete the Beneciary section on Page 3, you will not have a designated beneciary. In
that event, payment of any benet will be made in accordance with the Beneciary Provisions of the Group Policy.
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04/25/2018
31 Days TGP
SI 305-8199 PKT
Page 2 of 5 (12/17)
Standard Insurance Company GROUP LIFE INSURANCE
PORTABILITY FORM
Please complete reverse side (continued)
Please type or print. Complete entire form.
You may only continue amounts of Insurance that have been continuously in effect for at least 12 consecutive months
on the date your employment terminates. If you do not continue your Life Insurance, you may not continue any other
insurance that may be eligible for portability under the Group Policy. Accidental Death and Dismemberment (AD&D)
Insurance may not be continued.
Date you became insured under the Group Policy:
Has the amount of Insurance you wish to continue been continuously in effect for at least 12 consecutive months?
Employee Yes No Spouse Yes No Children Yes No
Is your employment terminating due to medical reasons? Yes No
Are you able to perform with reasonable continuity the material duties of at least one gainful occupation?
Yes No
Is your employment terminating because of retirement? Yes No
Are you planning to pursue other employment? Yes No
Billing: If approved, you will be billed quarterly (every three months), at your home address. Premium must be received
by the due date. There is no grace period for Portability of Insurance.
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Name: ____________________________________________________________________________________
(last) (rst) (middle)
Social Security Number: ___________________________ Telephone No.: ( )
Birthdate: ___________________________ Sex: M F
Address:
__________________________________________________________________________________
(street address)
(city) (state) (zip code)
(mo) (day) (year)
IDENTIFICATION
ELIGIBILITY
AMOUNT
Name of Policyholder:
Name of Employer, if different:
Group Policy No.:
Your occupation with the Policyholder/Employer:
Date you last worked for the Policyholder/Employer:
Employment termination date (if different):
If date you last worked and employment termination date differ, please explain:
GROUP POLICY
LIFE INSURANCE
PLAN 1 (BASIC) PLAN 2 (ADDITIONAL)
Employee: $ _______________________ $ _________________________
Spouse: $ _______________________ $ _________________________
Each Child: $ _______________________
Reset
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31 Days TGP
SI 305-8199 PKT
Page 3 of 5 (12/17)
I hereby apply to continue Insurance available under the terms of the Group Policy.
I agree that no coverage will take effect until it is approved in writing by Standard Insurance Company. I understand that if
my request is not accepted, any premium advanced by me will be refunded.
I understand that if I do not provide the beneciary designation form on le with the Policyholder/Employer, or if I do not
designate a beneciary in the Beneciary section above, payment of any benet will be made in accordance with the Beneciary
Provisions of the Group Policy.
I hereby represent that all statements contained herein are complete and true to the best of my knowledge and belief, and that
I meet all eligibility requirements for continued insurance under the Group Policy’s Portability Of Insurance provision. I have
read and understand the information herein.
FRAUD NOTICES
FOR RESIDENTS OF ARKANSAS, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO, OHIO,
OKLAHOMA, TENNESSEE AND WASHINGTON: Some states require us to inform you that any person who knowingly and
with intent to injure, defraud or deceive an insurance company, or other person, les a statement containing false or misleading
information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties,
depending upon the state. Such actions may be deemed a felony and substantial nes may be imposed.
FOR RESIDENTS OF COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information
to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, nes, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to the 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.
FOR RESIDENTS OF FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive an insurance
company, les a statement of claim or an application containing false, incomplete or misleading information is guilty of a
felony of the third degree.
FOR RESIDENTS OF MARYLAND, RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benet or who knowingly or willfully presents false information in an application for insurance
is guilty of a crime and may be subject to nes and connement in prison.
FOR RESIDENTS OF PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other
person les 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.
AGREEMENT
This beneciary designation: (1) revokes all prior designations, and (2) applies to basic and additional insurance, if any,
on your life that you continue under the Portability Of Insurance provision. A separate designation must be completed for
Supplemental Life Insurance, if any. Insurance on your Spouse or other Dependents, if any, is payable to you, if living, or as
provided under the terms of the Group Policy.
Insurance benets are only payable to a contingent beneciary if you are not survived by one or more primary beneciary(ies).
Unless specied otherwise: (1) the insurance benets will be divided equally between beneciaries in the same class (primary or
contingent), and (2) if a beneciary predeceases you, the beneciary’s share will be divided equally among surviving beneciaries
of the same class. If no beneciary (primary or contingent) survives you, payment will be made as provided in the Group Policy.
BENEFICIARY
Primary
Full Name % of Benet* Address
Social Security No. (if known) Date of Birth Telephone No. Relationship
Full Name % of Benet* Address
Social Security No. (if known) Date of Birth Telephone No. Relationship
*Percentage of Benet Total must equal 100%
Contingent
Full Name % of Benet* Address
Social Security No. (if known) Date of Birth Telephone No. Relationship
Full Name % of Benet* Address
Social Security No. (if known) Date of Birth Telephone No. Relationship
*Percentage of Benet Total must equal 100%
Signature: Dated:
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04/25/2018
31 Days TGP
SI 305-8199 PKT
Page 4 of 5 (12/17)
Employee’s Full Name: ______________________________________________________ Male Female
Employee’s Social Security Number: __________________________________ Birthdate: ____________________
Employee’s Occupation: _________________________________________________________________________
Policyholder Name: ____________________________________________________________________________
Employer Name, If Different: _____________________________________________________________________
Group Policy No.: ____________________________ Effective Date of Group Policy: _____________________
Is the employee’s Group Life Insurance ending because of employment termination? Yes No
If yes, date of employment termination: Date coverage ends:
Date employee last worked:
If no, reason for termination of employee’s Group Life Insurance:
Original effective date of coverage: Employee Spouse
Children
Amount of Insurance in effect on the date of employment termination:
LIFE INSURANCE
PLAN 1 (BASIC) PLAN 2 (ADDITIONAL)
Employee: $ _______________________ $ _________________________
Spouse: $ _______________________ $ _________________________
Each Child: $ _______________________
Amount of Insurance continuously in effect for at least 12 consecutive months:
LIFE INSURANCE
PLAN 1 (BASIC) PLAN 2 (ADDITIONAL)
Employee: $ _______________________ $ _________________________
Spouse: $ _______________________ $ _________________________
Each Child: $ _______________________
Is employment terminating due to medical reasons? Yes No
Is employment terminating because of retirement? Yes No
To your knowledge, is or will the terminating employee be eligible for any other group life insurance plan? Yes No
If yes, please explain: __________________________________________________________________________
Standard Insurance Company GROUP LIFE INSURANCE
PORTABILITY OF INSURANCE
POLICYHOLDER/EMPLOYER STATEMENT FOR PORTABILITY OF INSURANCE
Please type or print. Complete entire form.
PLEASE ATTACH ORIGINAL LIFE ENROLLMENT CARD OR FORM.
I hereby represent that the above information is true and complete to the best of my knowledge. In addition, I
acknowledge I have read the Fraud Notice on the back of this form.
TO BE COMPLETED BY POLICYHOLDER/EMPLOYER
By: _____________________________________________________
Date: ____________________________________ Name and Title: ___________________________________________
Telephone Number: _________________________ Address: _________________________________________________
Signature of Policyholder’s Representative
(Please Print)
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Printed
04/25/2018
31 Days TGP
SI 305-8199 PKT
Page 5 of 5 (12/17)
FRAUD NOTICES
FOR RESIDENTS OF ARKANSAS, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW MEXICO,
OHIO, OKLAHOMA, TENNESSEE AND WASHINGTON: Some states require us to inform you that any person who
knowingly and with intent to injure, defraud or deceive an insurance company, or other person, les a statement containing
false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject
to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial nes
may be imposed.
FOR RESIDENTS OF COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties
may include imprisonment, nes, denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to the 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.
FOR RESIDENTS OF FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive an insurance
company, les a statement of claim or an application containing false, incomplete or misleading information is guilty
of a felony of the third degree.
FOR RESIDENTS OF MARYLAND, RHODE ISLAND: Any person who knowingly or willfully presents a false
or fraudulent claim for payment of a loss or benet or who knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be subject to nes and connement in prison.
FOR RESIDENTS OF PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company
or other person les 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.
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Standard Insurance Company GROUP LIFE INSURANCE PORTABILITY FORM

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