Forms Required for a Conversion

1) New Term Conversion Application – Form # TRMCONV (REV 6/17).

2) A Needs Analysis

3) Certificate Illustration Routing Sheet and the Illustration

4) Bank Draft Authorization (if required) and a copy of a voided check only if a check was not submitted, unless you complete the routing and account numbers on the bank draft authorization.

5) Decrease Coverage Form – only used if member is doing partial decrease and keeping a minimum of $50,000.

HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA) form is not required.

SEND THE OLD CERTIFICATE if the member still has it.

AN APPLICATION FOR DECREASE OF INSURANCE is also required if you are doing a partial conversion.

Do not collect a premium until the conversion has been approved by underwriting. At that time underwriting will let you know what the correct premium is to collect.