Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the top portion of the form, which is designated for the policyholder. This includes entering the policyholder’s name, address, and, if applicable, the division name. Also, provide the policy number and the effective date of the insurance.
3. Fill in the insured’s full name, gender, date of birth, annual salary/earnings, social security number, date employment began, occupation/job title, and the date last worked.
4. Indicate the scheduled work hours per week. Provide details about the premium paid to the insured, the effective date of the insurance, insurance class, and the total insurance amount, which is typically broken down into basic and supplemental amounts.
5. Specify the reason the insured stopped working and indicate the relevant date if applicable (for instance, termination of employment or group policy). If there is a waiver of premium claim, select ‘yes’ or ‘no’ and provide additional explanations as necessary.
6. The authorized representative for the policyholder must sign, include their title, date of signing, and provide the federal employer identification number.
7. In the lower portion designated for the applicant, specify the amount of group life insurance coverage you wish to convert.
8. Select your desired mode of premium payment (quarterly, semi-annually, or annually). Fill in the beneficiary designation section by entering the names, addresses, relationships, and percentages for both primary and contingent beneficiaries.
9. Complete the applicant’s address, city, state, and zip code, along with a phone number. Review all entered information for accuracy.
10. Finally, the applicant must sign and date the form. After completing all steps, save changes, download the filled form, print it, or share it as needed.

Start completing your documents online today to ensure a smooth transition to your individual life insurance policy.