Member’s Name Today’s Date
Insured’s Name, if different Phone
Member’s Address City State Zip
Email Address
Please indicate the applications you will need. Please send application forms via:
Member
Spouse
Child – No. of children:
E-mail
Regular Mail
Group Name and Policy No. Termination or Reduction Date of Insurance
SI 1598-A (5/08)
Important Information for Owners of Group Life Insurance Certificates
We are happy to inform you that under your Standard Insurance Company Group Life Insurance coverage, you and your insured
dependents are offered the benefit of obtaining an individual life insurance policy. In order to take advantage of this opportunity,
we must receive an application and premium payment within 31 days of the date of cessation or reduction of group life
insurance coverage. This option to convert may be very valuable to you, as evidence of insurability will not be required. To take
advantage of the privilege of converting your insurance, please complete and return this form to the address above. We will
provide the necessary forms and information. For your convenience, at your election, we can send the information electronically
to your email address or we can mail the forms to your street address.
Member Information
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Standard Insurance Company
Continued Benefits
920 SW Sixth Avenue Portland OR 97204 800.378.4668 ext 6785
Request for Group Life
Conversion Materials
