Fillable death insurance to an individual policy. (Jordan School District)

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death insurance to an individual policy. (Jordan School District)

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... to convert your group accidental
death insurance to an individual policy.
This document outlines the conditions under which a person no longer eligible for
insurance under a Life Insurance Company of North America (LINA) Group Policy may convert to an
individual policy affording Accidental Death and Dismemberment (AD&D) benefits . . . including
Family coverage.
Now is the Time...
Take advantage of
this opportunity NOW!
LM-3P94h
Group Insurance
Life Accident Disability
2
Now is the Time!
Because...
YOU UNDERSTAND the value of Accident Insurance. You’ve been enrolled in a Plan of LINA Group Accident Insurance,
secure in the knowledge that your family will have the advantage of financial assistance in the event an accident results in
death or dismemberment.
Because...
WE UNDERSTAND your interest in continuing Your Accident Insurance Protection without interruption. LINA is providing
this opportunity to convert all or part of your current AD&D benefit, when your group coverage terminates because you
have ceased to be eligible, you have terminated employment with the policyholder, or the group policy has been can-
celled.
Because...
IT’S EASY TO CONVERT TO INDIVIDUAL COVERAGE. You can secure a new, individual LINA accident insurance
policy, without medical certification, for yourself—and for your eligible family members, whether or not they were insured
under your previous group policy.
You simply apply within 31 days after your group insurance terminates, and pay the premium for a new LINA policy at the
rate in effect for your attained age and occupation. Just forward the completed application, along with your check. You
can provide continued peace of mind to yourself and your family.
You can provide continued peace of mind to yourself and your family. You can easily convert your group accident insur-
ance to individual accident coverage. Now is the time!
Your Converted Policy
Will be effective on the date your group insurance terminates or on the date of your application, whichever is later.
The insurance pays for loss caused by, and occurring within one year after, an accident:
Loss of
Life ............................................................. Principal Sum
Two or more members*.............................. Principal Sum
One member .............................................. One-Half Principal Sum
Thumb and index finger of same hand....... One-Quarter Principal Sum
*“Member” means hand, foot or eye.
Only one amount, the largest to which you are entitled, is payable for all losses resulting from one accident.
Family Plan
Under the Family Plan, you may insure your family members as follows:
Your spouse under age 70, and your dependent child/ren (including step, foster and legally adopted children—and
children whose adoption procedures are pending)—under 19 years of age...or until age 25, if they are full-time students,
dependent on you for support and maintenance. Coverage will be extended for any dependent child who, upon reaching
the stated maximum age, is mentally or physically incapable of self-sustaining support and who is dependent upon you for
support and maintenance.
3
Selection of Your Principal Sum
If you were previously insured for less than $25,000, you may select the Principal Sum of $25,000.
If the amount for which you were previously insured appears in the PREMIUM SCHEDULE, you may select that amount
or any lower amount shown, but not less than $25,000.
If the amount for which you were insured does not appear on the PREMIUM SCHEDULE, you may select either a lower
figure or the next higher figure. (For example, if you were insured for $65,000 and want a higher amount, you may select
$75,000.)
If you insure your spouse and/or dependent child/ren under the Family Plan, the amount of insurance applicable to
members of the family is based on the composition of the family at the time of loss, and is expressed as a percentage of
your Principal Sum, as follows:
1) At time of loss the family consists of You, Your Spouse and Dependent Children
Employee .................................................................................................... 100%
Spouse .......................................................................................................... 40%
Each Child ..................................................................................................... 10%
2) At time of loss the family consists of You and Your Spouse but NO Dependent Child/ren
Employee .................................................................................................... 100%
Spouse .......................................................................................................... 50%
3) At time of loss the family consists of You and Your Dependent Child/ren but NO Spouse
Employee .................................................................................................... 100%
Each Child ..................................................................................................... 15%
Example: Under the Family Plan, you elect $100,000.
The family consists of you, your spouse, and three children.
Your Amount ................... $100,000.00
Your Spouse’s Amount ....... 40,000.00
Each Child’s Amount .......... 10,000.00
Limitations and Exclusions
The policy does not pay for loss caused by intentionally self-inflicted injuries; suicide (in Missouri, while sane); act of war,
declared or undeclared; loss resulting from accidents occurring while serving on full-time duty in the Armed Forces (pre-
mium will be prorated and returned for such period); commission of a felony by an insured; sickness, disease or infirmity.
Air travel is included while the insured person is traveling as a passenger only, in any plane, including MAC (Military Airlift
Command) or similar service of another country—but excluding travel in experimental or testing aircraft, or aircraft
designed for use beyond the earth’s atmosphere; hang gliding; parachuting (except for self-preservation); and while
serving as a pilot, crewmember, or student taking a flying lesson, in any aircraft.
General Information
The policy is renewable with Company consent until you reach age 70. The Company may change renewal premium
rates only on a class basis, not on an individual basis.
You may cancel at any time after the policy’s original term.
If you are insured under more than one LINA group contract with your present employer, you may convert each but a
separate application should be completed for each conversion.
Note: This individual insurance is not available if the Company has already issued you an individual AD&D policy con-
verted from a previous employer's plan.
4
Accidental Death and Dismemberment
Annual Premium Schedule
UNDER AGE 65
PRINCIPAL SUM INSURED ONLY INSURED & FAMILY
$ 25,000 $ 31.25 $ 45.00
50,000 62.50 90.00
75,000 93.75 135.00
100,000 125.00 180.00
125,000 156.25 225.00
150,000 187.50 270.00
200,000 250.00 360.00
250,000 312.50 450.00
AGE 65 UNTIL AGE 70
PRINCIPAL SUM INSURED ONLY INSURED & FAMILY
$ 25,000 $ 46.25 $ 67.50
50,000 92.50 135.00
75,000 138.75 202.50
100,000 185.00 270.00
125,000 231.25 337.50
150,000 277.50 405.00
200,000 370.00 540.00
250,000 462.50 675.00
To Calculate Your Premium
Select your Principal Sum and its appropriate annual premium. If you wish to pay the premium semiannually or
quarterly, please note:
For a selected Principal Sum of $50,000 or more, you may pay the premium semiannually by dividing the annual
premium by 2.
For a selected Principal Sum of $100,000 or more, you may pay the premium quarterly by dividing the annual
premium by 4.
Example: If at age 55, you select $100,000 of coverage for yourself with family coverage, Total Quarterly
Premium for You and Your Family = $45.00.
Your Costs
The rates shown below are for persons in Class I Occupational Classifications—i.e., individuals who are engaged
in the less hazardous occupations such as executives, managers, salesmen, accountants, lawyers, physicians,
surgeons. If your occupation falls into a more hazardous classification, LINA, upon receipt of your application,
will inform you of the rates that apply.
If your occupation changes to one more hazardous than is covered by the premium charged, payment for loss occurring
thereafter will be for that amount which the premium paid would have purchased. If your occupation changes to one less
hazardous, the premium will be reduced and any unearned amount will be returned.
If you have any questions or need assistance in completing the application, please call our toll-free number
1-800-441-1832 (TDD 1-800-552-5744), Monday through Friday, 8:00 a.m. to 5:00 p.m. (EST).
5
APPLICATION
for conversion of accidental loss of life, limb or sight coverage to an individual policy.
I have read the above statements and agree they are accurate and complete to the best of my knowledge and belief.
I understand that this insurance will be issued on reliance upon such statements.
Signature of Proposed Insured ________________________________________________ Date ______________________
This Part of Application to be Completed by Employer
GROUP POLICY NO._____________
_____________________________________________________________
on________________________ became ineligible for coverage under the group or blanket policy.
Prior to that date, the above individual was insured for: $______________________ Family Plan Yes No
Signed _____________________________________________________ Title _________________________________
for ___________________________________________ Subsidiary of__________________________________________
Telephone # _________________________ Date ______________
(Name of insured employee or of employee’s insured dependent)
(organization)
Complete this application and mail it along with your check (made payable to LINA) to:
Life Insurance Company of North America, P.O. Box 8500, S-6020, Philadelphia, PA 19178-6020.
Full Name _________________________________________ Social Security Number ______________________________
Address___________________________________________________________________________________________
Date of Birth __________ Former Occupation ______________________ Present Occupation _______________________
Describe Present Duties ________________________________________________________________________________
I wish to convert: Amount: $ __________ Family Coverage: Yes No
I wish to pay premiums: Annually Semiannually Quarterly
My check (made out to “LINA”) in the amount of $_________________ is enclosed.
Insured’s Beneficiary: Loss of life benefits will be paid to:
(Print full name of beneficiary and relationship to you) ________________________________________________________
Spouse’s Beneficiary: Loss of life benefits will be paid to the insured. All other benefits will be paid to the spouse.
Child’s Beneficiary: Loss of life and all other benefits will be paid to the insured.
Coverage: Accidental Death
and Dismemberment
This Part of Application to be Completed by Proposed Insured
6
IF THE PROPOSED INSURED HAS PREVIOUSLY ASSIGNED OWNERSHIP OF HIS/HER POLICY TO ANOTHER
PERSON FOR ESTATE TAX PURPOSES—OR NOW WISHES TO DO SO—BOTH THE PROPOSED INSURED AND
THE OWNER MUST SIGN THIS PART OF THE APPLICATION.
The answers to the questions contained in the application have been made by the proposed insured at the request
and on the behalf of the proposed Owner, and insurable interest in the proposed insured exists on the part of not
only the proposed Owner but also the beneficiary or beneficiaries designated in the application, which designation is
that of the proposed Owner.
The proposed Owner adopts as a part of the application all of the statements and answers of the proposed Insured.
The proposed Insured agrees and understands that the proposed Owner, as assignee of all the proposed insured’s
rights, privileges and interests under a group, blanket or individual policy, inclusive of a Conversion Privilege there-
under, is hereby exercising said Conversion Privilege and that all right, title and interest under the converted policy
for which this application is submitted will become vested in the person named herein as proposed Owner.
If any interest or payment shall not vest in the proposed Owner, or in the beneficiary or beneficiaries designated
hereunder, such interest or payments shall not revert to the proposed Insured or his/her estate but shall become
payable in such shares and to such persons as may be entitled to take from him/her under the intestate law of the
state of the Insured’s residence at the time of death.
Name of Proposed Owner _____________________________________________________________
Address ___________________________________________________________________________
City & State ________________________________________________________________________
Relationship to Proposed Insured _______________________________________________________
Dated at ___________________________________________ this day of ______________________
Signature of Proposed Owner __________________________________________________________
Signature of Proposed Insured _________________________________________________________
(month) (date) (year)
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Completed 21 February 2021

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