Request for continuation of group life insurance form - Harleysville ...

REQUEST FOR CONTINUATION OFVOLUNTARY GROUP TERM LIFE INSURANCEUnder the terms of your previous employer’s voluntary group term life policy, you may have the option to continue your voluntarygroup term life insurance benefits for yourself, your spouse and any eligible dependents. If you wish to continue your group termlife insurance, you must complete and submit this request form within 31 days from your date of termination as an eligibleemployee. Premium rates under the continuation feature will be the same as the premium rates paid by eligible employees under thegroup policy. Please note the following conditions and restrictions below:1. You cannot continue your life insurance if you are currently disabled.2. Spouse and/or Child life insurance may not be continued if your life insurance is not continued.3. The maximum amount of insurance you may continue on yourself, your spouse and eligible children is the amount in effect on thedate you were no longer an eligible employee, up to $125,000.4. Any rate changes that become effective for the Employer/Policyholder will apply to your continued life insurance on the same date.5. The group policy sponsored by the Employer/Policyholder must be active and remain active in order for your insurance to stay inforce.6. No changes in benefits are permitted after exercising the continuation feature7. If the group policy contains a waiver of premium and/or accelerated death benefit rider, these riders will not apply under thecontinuation provisions. All other policy provisions will apply.If you are not eligible to continue your group term life insurance under the Continuation provision -- you, your Spouse and anyeligible dependents may be eligible to convert the insurance to an individual Policy under the Conversion Provisions of this Policy.Please refer to your Certificate for additional details regarding the Conversion Provision, or contact us at (800)222-1981, ext. 3192,or by email at grouplifeadministration@harleysvillegroup.com.REQUEST FOR CONTINUATION OF VOLUNTARY GROUP TERM LIFE COVERAGEName of Employer/Policyholder (as listed on your insurance certificate)_____________________________________________________________Name (Last, First, Middle Initial)Group Account Number (as listed on your certificate)G_________________________________________Last: _______________________________First:______________________________M.I.:_____ Date of Birth: _______________Gender: _____ SS# _______________ Date of Hire:____________ Premium Mode: Annual Semi-Annual QuarterlyA $2.00 billing fee will apply for each bill issued.Current Mailing Address:Email Address:__________________________________Street: _______________________________________________Apt #: ________ Phone: (______)_______-__________City: _________________________________State: ________Zip: _____________ Work: (______)_______-__________Please select coverage(s) and amount(s) of coverage to be continued :Employee’s Life Insurance $________________Spouse Life Insurance $ ________________Spouse Name:_____________________________________Date of Birth:___________ SS #: _____________________Child(dren) Life Insurance $ ________________Child Name Date of Birth Full-Time Student_______________________________________________ Yes No_______________________________________________ Yes No_______________________________________________ Yes No_______________________________________________ Yes NoSpouse and Child(ren) coverage cannot be continued unless employee's coverage is continued.Date employment terminated with the aboveemployer: ______________________Reason for Termination:Termination of employmentLaid offLeave of AbsenceOther (explain):__________________________________________________________Are you currently disabled? Yes NoIf Yes, date last worked:__________________By my signature I affirm that the statements and answers made herein are complete and true to the best of my knowledge andbelief.Employee Signature: _______________________________________________Date:_________________1 GM-012 (Ed. 05-12)

REQUEST FOR CONTINUATION OF VOLUNTARYGROUP TERM LIFE COVERAGEBENEFICIARY DESIGNATION FOR PRIMARY INSURED (The primary insured is the beneficiary for spouse and child coverage.)Primary Insured Name:_________________________________________________________________________PRIMARY BENEFICIARY DESIGNATIONName: _________________________________________Social Security Number: ___________________________Date of Birth: ____________________________________Relationship to Applicant: __________________________Home Address: ____________________________________________________________________Beneficiary Phone #: ______________________________Percentage Share: ______% (Total for all primary beneficiariesmust equal 100%)Name: _________________________________________Social Security Number: ___________________________Date of Birth: ____________________________________Relationship to Applicant: __________________________Home Address: ____________________________________________________________________Beneficiary Phone #: _____________________________Percentage Share: ______% (Total for all primary beneficiariesmust equal 100%)Name: _________________________________________Social Security Number: ___________________________Date of Birth: ____________________________________Relationship to Applicant: __________________________Home Address: ____________________________________________________________________Beneficiary Phone #: _____________________________Percentage Share: ______% (Total for all primary beneficiariesmust equal 100%)CONTINGENT BENEFICIARY DESIGNATIONPayment will be made to contingent beneficiary(ies) if all primarybeneficiaries are deceased.Name: ___________________________________________Social Security Number: _____________________________Date of Birth: ______________________________________Relationship to Applicant: ____________________________Home Address: ________________________________________________________________________Beneficiary Phone #: ________________________________Percentage Share: ______% (Total for all contingentbeneficiaries must equal 100%)Name: ___________________________________________Social Security Number: _____________________________Date of Birth: ______________________________________Relationship to Applicant: ____________________________Home Address: ________________________________________________________________________Beneficiary Phone #: _______________________________Percentage Share: ______% (Total for all contingentbeneficiaries must equal 100%)Name: ___________________________________________Social Security Number: _____________________________Date of Birth: ______________________________________Relationship to Applicant: ____________________________Home Address: ________________________________________________________________________Beneficiary Phone #: _______________________________Percentage Share: ______% (Total for all contingentbeneficiaries must equal 100%)REQUIRED SIGNATURES FOR BENEFICIARY DESIGNATIONI acknowledge that the information contained above for beneficiary designations is true and accurate.Date _______________________ ________________________________________________________________________Employee/Member Signature2 GM-012 (Ed. 05-12)