Get Employee Application For Conversion Coverage Long Term ...

Completing the Employee Application For Conversion Coverage Long Term Disability Insurance online can streamline the process of maintaining your long-term disability coverage. This guide provides clear instructions on how to accurately fill out each section of the form, ensuring a smooth submission.

Follow the steps to complete the application efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin with the first section labeled 'Prospective person insured.' Provide the date of birth for the individual applying for coverage.
3. In the 'Address' section, fill in the number and street, city, state, and zip code of the applicant.
4. Next, specify the group policyholder name and group policy number. Ensure these details are accurate as they link the application to the correct policy.
5. Enter the certificate number and group insurance effective date. These are typically found on the original group policy documents.
6. Provide the social security number of the prospective insured and the termination date for the group insurance.
7. State the reason for termination of the group insurance. Be clear and concise to avoid misunderstandings.
8. Indicate if there is any other Long Term Disability coverage currently in effect or if one has been applied for. If 'Yes,' provide further details as requested.
9. Fill out the initial premium amount. Remember, checks must be made out to Union Security Insurance Company.
10. Review the declaration where you must acknowledge the terms of the conversion policy. Sign and date the application in the designated fields.
11. The group policyholder must complete the verification section, providing their name, signature, and confirmation of all necessary details.
12. Finally, review the entire document to ensure all entries are accurate and complete. Save changes, download, print, or share the form as needed.

Complete your application online today for a seamless transition to conversion coverage.