Fillable Standard Insurance Company Third Party Notice Request Form

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Standard Insurance Company Third Party Notice Request Form

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60 Days ID
SI 19642
1 of 10 (2/18)
Standard Insurance Company
Third Party Notice Request Form
For Use In Idaho
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Idaho law requires that insureds be given the option to designate a third party to receive notice of impending
termination of insurance coverage due to nonpayment of premium. If you wish to designate a third party to
receive such notice, please provide the following information and return this form to us with your Application for
Conversion of Group Insurance. Please print all information.
If you do not choose to make a designation at this time, no further information is required. However, you retain the
right to designate a third party at any time in the future, and you may change your designation at any time.
Your Name
Your Street Address
Your City, State, Zip Code
Your Signature
Date
Third Party’s Name
Third Party’s Street Address
Third Party’s City, State, Zip Code
Third Party’s Phone Number
Reset
60 Days
SI 9563
2 of 10 (12/17)
Thank you for asking for more information about converting your group term life insurance to individual coverage.
If you are terminating employment due to sickness or injury, please contact your employer to determine eligibility for disability
or Waiver of Premium benets before completing this application for conversion.
If you convert your group insurance coverage, you’ll have continued protection with premiums payable to age 100. This policy
will accumulate cash value, and will allow you to borrow against the cash value if sufcient. Interest on the policy loan will accrue
daily and will be at a xed rate (subject to policy terms and applicable state law). The policy does not share in dividends.
The amount of insurance you may convert depends on the reason for the cessation of your group insurance coverage. If
your group life insurance coverage ended for any reason other than your failure to make a required premium contribution
or the termination of the group policy, the maximum amount you can convert is the amount of your life insurance which
ended. If your life insurance ended because of the termination or amendment of the group policy, or if your insurance has
been reduced, then the amount you can convert may be different. Please refer to your Certicate of Insurance or contact
Standard Insurance Company for a full description regarding the amount you may be entitled to convert.
To calculate your premium payments, use the attached Schedule of Rates and worksheet.
To complete the conversion, you must return the enclosed application form and your check for the rst premium payment
within 60 days after the termination of your group insurance. Your application to convert your insurance may not be valid if
received in our ofce after this 60 day period. If you had group life insurance on your dependents and want to convert their
coverage also, please contact us for additional applications. Your former employer or group policyholder must also complete
the Employer’s Certication and send it to us. This application will be attached to and made part of the policy.
If you have any questions about the application or other conversion options, our ofce is available to assist you. We look
forward to continuing to provide you with life insurance protection.
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Group Conversion Packet
60 Days
SI 9563
3 of 10 (12/17)
*Add $40.00 annual policy fee to nal premium. These premium rates are not guaranteed and are subject to change by Standard Insurance Company.
Annual Premium per $1,000*
Form G1.3
0 18.55
1 18.64
2 18.74
3 18.83
4 18.93
5 19.02
6 19.12
7 19.21
8 19.31
9 19.41
10 19.50
11 19.60
12 19.70
13 19.80
14 19.90
15 20.00
16 21.25
17 21.67
18 21.87
19 22.20
20 22.30
21 22.35
22 22.48
23 22.57
24 22.63
25 22.70
26 22.79
27 22.89
28 23.02
29 23.23
30 23.60
31 24.05
32 24.55
33 25.15
34 25.81
35 26.50
36 27.25
37 28.00
38 28.86
39 29.90
40 31.00
41 32.25
42 33.75
43 35.32
44 36.75
45 38.50
46 40.32
47 42.25
48 44.45
49 46.75
50 49.08
51 51.74
52 54.50
53 57.60
54 61.00
55 64.70
56 68.62
57 72.80
58 77.40
59 82.20
60 87.60
61 93.53
62 99.94
63 106.22
64 112.85
65 119.75
66 127.02
67 134.77
68 143.01
69 151.88
70 159.21
71 167.08
72 178.00
73 192.12
74 206.37
75 222.60
76 240.06
77 258.80
78 279.82
79 302.24
80 325.90
81 351.11
82 377.34
83 405.32
84 435.22
85 466.82
Age Premium Age Premium Age Premium
Group Conversion Whole Life
Premium Rates
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
4 of 10 (12/17)
1. Determine the amount of insurance you want to convert.
2. Determine whether you want to pay your premium annually, semi-annually, quarterly or monthly. The less frequently you pay
the premium, the lower the rate will be.
3. Find your premium from the chart on page 2. The premium is based on the requested face amount of your policy and your
age. (Please note: If your next birthday is less than 6 months away, add one year to your current age.)
Age:
4. Calculate your premium:
a) The number of thousand dollar units of coverage you
want. (Example: $50,000 is 50 units.)
b) Rate. Using age listed in no. 3 above, nd the premium
per $1,000 on the chart (see page 2). x
c) Multiply (a) times (b). = $
d) Add $40.00 annual policy fee.
+
$40.00
e) This is your annual premium due. = $
f) If not paying annually, multiply the annual premium in (e) by
the applicable pay factor below (select one):
1. semi-annually .516
2. quarterly .265
3. monthly .094 x
g) This is the premium amount due for the pay frequency you selected =
(if not annual). (Pay factor in (f) times annual premium in (e).)
5. If Paying monthly, please include 2 months premium with your application.
EXAMPLE
1. A 40 year old group insured is converting $50,000 of his/her group coverage to an individual whole life policy of $50,000.
2. The group insured wants to pay premiums monthly.
3. The annual premium rate for a 40 year old is $31.00 for each $1,000 of coverage.
4. Premium calculation (see no. 4 above):
a) 50 units (50,000 ÷ 1,000)
b) $31.00 (use age of 40 and nd rate on the Whole Life Policy chart)
c) $1,550.00 ($31.00 x 50)
d) Add $40.00 annual policy fee
e) $1,590.00 (total annual premium) ($1,550.00 + $40.00)
f) x .094 (monthly pay factor)
g) $149.46 due each month ($1,590.00 x .094)
Worksheet for Calculating Your Premium
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
5 of 10 (12/17)
Please complete all blanks (except for Federal group insurance conversions, for which date of termination of employment is
omitted). It is important to use full given name of insured (not initials) and show the date of birth accurately. If you make any
changes on the application, please initial and date the change.
1. Check box to indicate who is converting: Member, Spouse, or Dependent Child.
2. Name of Group Policyowner. Please show complete name of Company, Union, Association, Government Unit, etc.
Example: John Doe Manufacturing Company.
3. Amount of coverage requested. This amount is to be determined as follows:
a. It may not exceed the face value of your Group Life Insurance on the date of termination.
b. If your group life insurance coverage includes a portability option, and you choose to continue a portion of your
insurance under that provision, you are eligible to convert only the balance of your Group Life coverage.
4. Premium Payable. You must include your rst premium with your application. If you are paying monthly, please include
two months of premium with your application.
5. Automatic Premium Loan Provision. The provision is designed to prevent lapse of your policy in case your premium is not
paid by the end of the grace period. As long as the policy has sufcient cash value, an automatic policy loan will be made
to pay any premium which has not been paid on time. You will be notied of the loan. It may be repaid within 60 days
without interest. The interest rate will be shown in your policy.
6. Full Name of Beneciary. The beneciary is the person named to receive the death benet. Unless otherwise requested,
any amount payable at the death of the Insured is paid in equal shares to the Primary Beneciaries, if living, or if none is
living, in equal shares to the then surviving Contingent Beneciaries of highest rank. If no beneciary is then living,
payment is made to the owner or the owner’s estate. Please show the full given name for a married woman (Jane L. Doe,
not Mrs. John L. Doe).
7. Signature. Please sign the form at the bottom. Include your address. If the application is for a dependent child under age
18, the signature of the child’s parent is required. If a guardian has been named, the guardian must sign and a copy of the
Letters of Guardianship should accompany the application.
8. Please complete Taxpayer Identication Number (TIN) Certication on the back of the conversion application.
Instructions for Completing Application
for Group Conversion
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
6 of 10 (12/17)
This application must be completed and signed by the person to be insured. Please print all responses.
IDENTIFICATION
Name of Proposed Insured: (rst, middle, last)
Street Address:
City: State: Zip Code:
Telephone: Birthdate:
Proposed Insured is: Sex:
Group Member Spouse Dependent Male Female
FOR MINOR INSURED: Give total amount of all other life insurance currently in force on this minor insured: $
GROUP POLICY
Name of Group Policyowner: Group Policy No.:
Amount of Group Life Insurance on termination date: $
Member’s employment and/or membership terminated on: (month, day, year)
DISABILITY
Are you currently unable to work because of sickness or injury? Yes No
If yes, please contact your employer to determine eligibility for disability or waiver of premium benets.
CONVERSION
Amount of individual coverage requested: $
Do you want automatic premium loan provision?
Yes No
Premium shall be payable: (check one)
Annually Semi-annually Quarterly Monthly
Amount paid with this application: $
(Follow instructions in this packet for determining premium amount. Your check must be payable to Standard Insurance Company.)
Birth DateAddress
Primary – Full Name
Phone No. Relationship
Soc. Sec. No.
if known
% of Benet
Total must
equal 100%
Birth DateAddress
Contingent – Full Name
Phone No. Relationship
Soc. Sec. No.
if known
% of Benet
Total must
equal 100%
BENEFICIARY (If the insured is a minor, the beneciary must be the minor’s estate.)
This application will be attached to and made part of the policy. Please complete back of form.
OWNER
OWNER: The owner of the new policy will be the insured if age 18 or older on the date this application is signed, UNLESS a different
owner is named here.
Owner (if other than insured) (must be 18): Address:
(If the insured is under age 18, the owner must be the child’s parent or guardian.)
Application for Conversion of
Group Insurance
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
7 of 10 (12/17)
AGREEMENT
Application is made to Standard Insurance Company, to convert my group coverage to an individual life insurance policy as requested
above. I agree that all requests shall be subject to the provisions and conditions of the policy and to the company’s usual procedures
governing any action taken based on this application. I acknowledge that I have read the fraud notice on page 7 of this form.
Dated: Signature of Insured:
Signature of Owner: (if different from insured) Parent’s or Guardian’s Signature: (if insured is dependent child)
ALL APPLICATIONS
Taxpayer Identication Number (TIN) Certication
(APPLICANT MUST SIGN AND DATE BELOW, AND GIVE TIN, ON ALL APPLICATIONS.)
We are required by law to obtain the following information. Please ll in the owner’s social security number (or other TIN).
Draw a line through no. 2 only if it is not correct.
Certication – Under penalties of perjury, I certify that:
1. The number shown on this form is my correct Taxpayer Identication Number (or I am waiting for a number to be
issued to me), and
2. I am not subject to backup withholding either because: I have not been notied by the Internal Revenue Service (IRS)
that I am subject to backup withholding as a result of a failure to report all interest or dividends; or the IRS has noti-
ed me that I am no longer subject to backup withholding.
Home Ofce Only – Item(s) no. changed to:
Date: Owner’s Soc. Sec. or TIN Number: Applicant/Owner’s Signature:
This application will be attached to and made part of the policy.
Application for Conversion of
Group Insurance (Cont.)
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
8 of 10 (12/17)
Group Conversion Packet
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Some states require us to provide the following information to you:
ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS
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.
CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to nes and connement in state prison.
COLORADO RESIDENTS
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.
DISTRICT OF COLUMBIA RESIDENTS
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or nes. In addition, an insurer may deny insurance benets, if false
information materially related to a claim was provided by the applicant.
FLORIDA RESIDENTS
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
NEW JERSEY RESIDENTS
Any person who knowingly les a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.
NEW YORK RESIDENTS
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 shall also be subject to civil
penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA RESIDENTS
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.
ALL OTHER RESIDENTS
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.
60 Days
SI 9563
9 of 10 (12/17)
To Insured: Please give this form to your employer to complete.
To Employer: Please complete the entire form. Please print or type.
TO BE COMPLETED BY FORMER EMPLOYER
Member’s Name: Social Security Number:
Group Policyowner: Policy Number:
Date of Membership/Hire Effective Date of Insurance: Member’s Termination Date:
Amount of Group Life Insurance on Termination Date (list amount of each coverage separately):
Basic Insurance $ Additional Insurance $
Supplemental $ Other (specify) $
Did This Member Have Dependent Coverage?
Yes No
Please Indicate the Amount of Dependent Coverage: Spouse $ Child $
Member’s Insurance Class, as Dened by the Policy:
Reason for Termination:
Monthly Salary on Termination Date: $ per month
Effective Date of Last Salary Change:
Was a Summary Plan Description or Certicate of Insurance Delivered to the Member?
Yes No
Please attach original enrollment/beneciary card. This is required.
I hereby certify that was an insured Member under the above Group Policy
and was insured for the coverage amounts noted above. I acknowledge that I have read the fraud notice on page 9 of this form.
Signature: Date:
Name (print) and Title: Telephone Number:
Street Address:
City: State: Zip Code:
( )
Employer’s Certication for Conversion
of Group Life Insurance
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
60 Days
SI 9563
10 of 10 (12/17)
Group Conversion Packet
Standard Insurance Company
Continued Benets
800.378.4668 Tel 800.331.3397 Fax
900 SW Fifth Avenue Portland OR 97204
Some states require us to provide the following information to you:
ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS
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.
CALIFORNIA RESIDENTS
For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to nes and connement in state prison.
COLORADO RESIDENTS
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.
DISTRICT OF COLUMBIA RESIDENTS
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or
any other person. Penalties include imprisonment and/or nes. In addition, an insurer may deny insurance benets, if false
information materially related to a claim was provided by the applicant.
FLORIDA RESIDENTS
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
NEW JERSEY RESIDENTS
Any person who knowingly les a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.
NEW YORK RESIDENTS
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 shall also be subject to civil
penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA RESIDENTS
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.
ALL OTHER RESIDENTS
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.
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Standard Insurance Company Third Party Notice Request Form

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Completed 6 November 2021

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