Fillable Standard Insurance Company Group Life Portability Insurance Application (Desoto County, Florida)

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Standard Insurance Company Group Life Portability Insurance Application (Desoto County, Florida)

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SI 9178 1 of 7 (1/13)
INSTRUCTIONS – PLEASE READ CAREFULLY
Portability Of Insurance
You may be eligible to buy portable Group Life Insurance if your employment with your employer terminates. If your employer’s
Group Life Insurance plan includes Accidental Death and Dismemberment (AD&D) and/or Dependents Insurance, you may
also be eligible to buy those coverages.
To be eligible, you must meet the following requirements:
1. You must have been continuously insured under your employer’s Group Life Insurance plan 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 fi tted by education, training and experience on the date your employment terminates.
3. You must be under age 65 on the date your employment terminates.
4. If you do not buy Life Insurance for yourself, you may not purchase any other insurance coverages.
The minimum and maximum amounts of insurance eligible for Portability Of Insurance are shown in your employer’s Group
Life Insurance plan. The amounts of insurance you purchase under the Portability Of Insurance provision cannot be increased.
NOTE: Refer to the Right To Convert provision in your employer’s Group Life Insurance plan for information regarding eligibility
to convert to an individual life insurance policy. The combined amounts of insurance you purchase under the Portability Of
Insurance provision and insurance you convert may not exceed the amount for which you or your Dependents were insured on the
day before your employment terminates. You may also wish to contact an independent insurance agent to discuss other alternatives.
How to Apply
You must apply in writing and pay the fi rst premium to us within 31 days after the date your employment terminates. This
packet has two forms: one for you and one for your employer. You are responsible for making sure all required forms are
completed and returned to our offi ce. Processing will begin when both fully-completed forms and all applicable enrollment
forms are received by us. If you have questions, please contact our offi ce at the phone number shown above.
Premium rates are shown on Page 2 of this application, and are subject to increase with advancing age. Premium rates may be changed
by Standard Insurance Company (The Standard) with advance written notice. Approved applicants will be billed quarterly (every three
months). Checks are to be made payable to The Standard. Premium must be received by the due date.
If your application is approved, you will receive a Group Life Portability Insurance certifi cate which will provide a complete
description of coverage. The Group Life Portability Insurance certifi cate will contain provisions that will be different from
your employer’s Group Life Insurance plan.
Please note:
Approved amounts will be reduced or terminated according to the terms of the Group Life Portability Insurance Policy.
Group Life Portability Insurance ends automatically on the earliest of:
1. The date it would otherwise end under the Group Life Portability Insurance Policy.
2. The date the last period ends for which we received the required payment.
3. The date the Group Life Portability Insurance Policy terminates.
4. The date you become a full-time member of the armed forces of any country.
5. For any AD&D Insurance:
a. The date you reach age 65.
b. The date your Life Insurance ends.
6. For any Spouse Insurance, the date of your divorce or legal separation.
7. For any Dependents Insurance:
a. The date your portable Life Insurance ends.
b. The date the Dependent ceases to be a Dependent.
8. Your check will be deposited into a conditional receipts account while your application is pending. This does not
constitute approval of your application or waiver of the policy’s eligibility requirements. If we determine that you are
not eligible for coverage, all funds will be returned to you.
Benefi ciary Designation
Benefi ciary designations that you made under your employer’s Group Life Insurance plan will not apply to Group Life Portability
Insurance. If you wish to designate a benefi ciary for Group Life Portability Insurance, please complete the Benefi ciary section
on Page 4. If you do not designate a benefi ciary, payment of any benefi t will be made in accordance with the Benefi t Payment
and Benefi ciary Provisions of the Group Life Portability Insurance Policy.
Group Life Portability Insurance Application
Standard Insurance Company
800.378.4668 ext. 6785 800.331.3397 Fax
920 SW Sixth Avenue Portland OR 97204-1203
Printed
12/31/2012
SI 9178 2 of 7 (1/13)
1. Age
2. Monthly Rate for age from above table
3. Amount of Insurance
4. Divide Line 3 by 1,000
5. Multiply Line 4 by Line 2
6. Add all amounts in Line 5 to arrive at Monthly Premium Amount
$
TOTAL PREMIUM DUE
GROUP ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE (if applicable)
Monthly Premium Rate is $0.04 per $1,000 of AD&D Insurance
a. Amount of Insurance from Line 3
b. Divide Line a by $1,000
c. Multiply Line b by $0.04 to arrive at Monthly Premium Amount
$
Member Only
GROUP LIFE and, if applicable, DEPENDENTS LIFE INSURANCE
Monthly Premium Rates for Member & Spouse per $1,000 of Insurance
Age
(on last birthday) Non-Tobacco Rate Tobacco Rate
0-34 $ 0.16 $ 0.22
35-39 0.17 0.24
40-44 0.23 0.34
45-49 0.39 0.56
50-54 0.56 0.81
55-59 0.97 1.38
60-64 1.47 2.09
65-69 2.87 3.98
70-74 4.70 6.31
75-79 6.99 9.05
80+ 12.82 16.00
Member Spouse Child
$0.16 per $1,000
Premium Computation Worksheet
Standard Insurance Company
800.378.4668 ext. 6785 800.331.3397 Fax
920 SW Sixth Avenue Portland OR 97204-1203
Add Line 6 to Line c above (if applicable) $
Multiply by 3 to arrive at TOTAL QUARTERLY PREMIUM DUE $
Reset
Printed
12/31/2012
SI 9178 3 of 7 (1/13)
Member $ $
Spouse $ $
Children $
Please type or print.
COMPLETE ENTIRE FORM.
3. EMPLOYER INFORMATION
Name of group Group Number
Name of employer (if different) Employer HR Contact and Phone Number
Your occupation with the employer
Date you last worked for the employer Employment termination date (if different)
If date you last worked and employment termination date differ, please explain:
1. MEMBER INFORMATION
Name (last, fi rst, middle) Sex
Street address City State Zip code
Social Security No. Telephone Birthdate (month, day, year)
Male Female
4. ELIGIBILITY
Date you became insured under your Employer’s coverage under the Group Policy
Have you been insured under your Employer’s group life insurance plan for at least 12 consecutive months?
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 for which you are reasonably
fi tted by education, training and experience?
Yes No
Are you under the age of 65 on the date your employment terminates?
Yes No
Have you or your spouse used tobacco in any form in the last 12 months? Member:
Yes No Spouse: Yes No
Spouse name (last, fi rst, middle) Spouse birthdate (month, day, year)
2. DEPENDENTS INFORMATION (if applicable)
(continued)
5. AMOUNT OF INSURANCE COVERAGE REQUESTED
GROUP LIFE and, if applicable, DEPENDENTS LIFE INSURANCE
Billing: If approved, you will be billed quarterly (every three months), at your home address. Premium must be received by the due date.
AD&D INSURANCE (if applicable)
Member Statement for Group Life
Portability Insurance
Standard Insurance Company
800.378.4668 ext. 6785 800.331.3397 Fax
920 SW Sixth Avenue Portland OR 97204-1203
Printed
12/31/2012
SI 9178 4 of 7 (1/13)
6. BENEFICIARY
This benefi ciary designation applies to all of your Group Life Portability Insurance and Accidental Death and Dismemberment Insurance,
if any.
If you name two or more benefi ciaries in a class (primary or contingent): (1) Two or more surviving benefi ciaries will share equally,
unless you provide for unequal shares. (2) If you provide for unequal shares in a class, and two or more benefi ciaries in that class survive,
we will pay each surviving benefi ciary his or her designated share. Unless you provide otherwise, we will then pay the share(s) otherwise
due to any deceased benefi ciary(ies) to the surviving benefi ciaries pro rata based on the relationship that the designated percentage or
fractional share of each surviving benefi ciary bears to the total shares of all surviving benefi ciaries. (3) If only one benefi ciary in a class
survives, we will pay the total death benefi ts to that benefi ciary.
If no benefi ciary (primary or contingent) survives you, payment will be made as provided in the Group Life Portability Insurance Policy.
Insurance on your Spouse or other Dependents, if any, is payable to you, if living, or as provided under the terms of the Group Life
Portability Insurance Policy.
Note: If death occurs and a minor is the benefi ciary, it may be necessary to have a guardian or a legal representative appointed before any
death benefi t can be paid.
Primary
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Contingent
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Full Name % of Benefi t Address
Social Security No. (if known) Date of Birth Relationship
Printed
12/31/2012
SI 9178 5 of 7 (1/13)
7. AGREEMENT
I hereby apply for Group Life Portability Insurance.
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 designate a benefi ciary in the Benefi ciary section on the preceding page, payment of any benefi t will be
made in accordance with the Benefi t Payment and Benefi ciary Provisions of the Group Life Portability Insurance 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. I have read and understand the information herein, including the applicable Fraud Notice below.
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, fi 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 fi 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, fi 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, fi 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 AND RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefi t or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fi nes and confi nement in prison.
FOR RESIDENTS OF PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person
fi 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.
Signature Date
Printed
12/31/2012
SI 9178 6 of 7 (1/13)
Member $ $
Spouse $ $
Children $
1. MEMBER INFORMATION
Please type or print. ENTIRE FORM MUST BE COMPLETED BY EMPLOYER.
Full name Sex
Social Security No. Birthdate Occupation
Member’s Insurance Class, if any, as defi ned by the Group Policy
Male Female
2. EMPLOYER INFORMATION
Group name Employer name (if different)
Group number Effective date of Employer’s coverage under the Group Policy with The Standard
Is the Member’s Group Life Insurance terminating because employment is ending? Yes No
If yes, date employment ended Date coverage ends
Date Member last worked
If no, reason for termination of Member’s Group Life Insurance
Is employment terminating due to medical reasons?
Yes No
Original effective date of Member’s coverage as your Employee (including with your prior carrier)
4. ANNUAL EARNINGS
Annual earnings on the last day of active work
Date of the last pay increase/decrease
Annual earnings prior to the last pay increase/decrease
3. AMOUNT OF INSURANCE
GROUP LIFE and, if applicable, DEPENDENTS LIFE INSURANCE
AD&D INSURANCE
(if applicable)
Basic Additional (if applicable)
5. EMPLOYER AUTHORIZATION
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 next page.
Signature of authorized representative Date
Name and title (please print or type)
Address Direct telephone number
6. ATTACHMENTS
PLEASE ATTACH COPIES OF ALL LIFE ENROLLMENT FORMS
Note: If enrollment forms are not provided, it may prevent us from approving the application.
Employer Statement for Group Life
Portability Insurance
Standard Insurance Company
800.378.4668 ext. 6785 800.331.3397 Fax
920 SW Sixth Avenue Portland OR 97204-1203
Printed
12/31/2012
SI 9178 7 of 7 (1/13)
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, fi les a statement containing false or mislead-
ing 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 fi 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, fi 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, fi 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 AND RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benefi t or who knowingly or willfully presents false information in an application for insurance
is guilty of a crime and may be subject to fi nes and confi nement in prison.
FOR RESIDENTS OF PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or
other person fi 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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Printed
12/31/2012
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Standard Insurance Company Group Life Portability Insurance Application (Desoto County, Florida)

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