To submit this form, complete all required fields and ensure your employer or administrator signs the appropriate section. Mail the entire form to the following address within 31 days of your group coverage termination: ING Employee Benefits, Group Conversions, Route 8525, PO Box 20, Minneapolis, Minnesota 55440-0020. For any questions or if you do not receive information within 21 days of submission, call (800) 955-7736. It's advisable to double-check the filled information and ensure timely mailing to avoid gaps in coverage.

Ensure you submit the Life Conversion Information Request Form within 31 days of group coverage termination. Important dates to remember include your employment termination date and the insurance termination date.

The purpose of this form is to facilitate the conversion of group life insurance policies to individual life insurance policies after the termination or reduction of group coverage. It provides a structured format for collecting essential information from both employers and employees, ensuring a smooth transition process. Completing this form promptly helps maintain continuous life insurance coverage and secures financial protection for policyholders and their families.

• 1. Group Policyholder or Plan Name: Indicates the name of the employer or group policyholder.
• 2. Policy Number: Unique identification number of the insurance policy.
• 3. Employee's Name: Full name of the employee requesting conversion.
• 4. Date of Birth: Employee's date of birth.
• 5. Social Security Number: Employee's social security number for identification.
• 6. Disability Status: Indicates if the employee is disabled and the date of disability onset.
• 7. Coverage Termination Date: Date when the group insurance coverage ends.
• 8. Amount of Coverage: Total amount of insurance coverage eligible for conversion.
• 9. Signature: Signature of the employer or plan administrator.
• 10. Requestor Name: Full name of the person requesting the conversion.
• 11. Relationship to Employee: Describes the requestor's relationship to the employee.
• 12. Home Address: Street, city, state, and ZIP code of the requestor's residence.

Failure to submit this form within the specified time frame can result in loss of continuity in life insurance coverage. It may lead to a lapse in protection for you and your dependents.

• Loss of Coverage: You might lose your eligibility to convert group life insurance to individual coverage.
• Financial Risk: Without life insurance, the financial burden on your family could increase significantly.

• 1. Employment Termination: When your job ends, and you need to convert your life insurance.
• 2. Retirement: Upon retiring and needing to maintain life insurance coverage.
• 3. Reduction of Coverage: If your group life insurance benefits are reduced.
• 4. Loss of Dependent Status: When dependents need to convert their coverage due to a change in status.
• 5. Disability: When disabled employees need to convert their coverage.