Forms > Group Administration
Conversion
Use this form when an employee's group life insurance is reduced or cancelled due to age or termination of employment.
Note: Because employees have only 31 days* from the date of reduction or termination to exercise the conversion privilege, it is extremely important that you provide them with this form on or before the date of reduction/termination.
*Applicants in the state of Minnesota have 60 days.
The Employer/Plan Administrator (or an authorized representative) should complete the top portion of the form, including:
- Name, Sex, Date of Birth and Address of the Employee
- Amount of Insurance:
- Terminations-not more than amount in force prior to termination of coverage
- Reductions- not to exceed amount of coverage reduced by age
- Insurance Termination or Reduction Date
- Policy Number
- Name of Group
- Date of this Notice (date form is given to employee)
- Employer Authorized Signature
The Employee should complete the remainder of the form.
Important:
The correct Request for Conversion form should be selected in accordance with the state of Issue for the Group Contract. Please choose the appropriate state from the list below.
When the form is complete, mail the original copy to the Group Conversion Department at Boston Mutual. The employer should retain a copy of the conversion form for their records.