Phone Number Date Group Life Benefits Became Effective for Insured (mm/dd/yyyy) Reason for Termination: Termination of Employment Termination of Group Policy or Class Retirement No Longer an Eligible Dependent Total Disability Coverage Information If the group policy or a class under the Complete the relevant column based on the event policy is ending, complete the applicable triggering conversion. If coverage is ending due to fields below. The amount of coverage termination of employment available for conversion is the lesser of If an accelerated benefits option claim was paid, or eligibility, or is reducing, the amount lost, or $10,000, provided the reduce the amount available for conversion by the complete the applicable insured was covered under the plan for at ABO claim amount. fields below. least five years. Group Policy Coverage Amount. Cannot Exceed Coverage Type Report Number Coverage Amount $10,000 Basic Life Supplemental Life Dependent Spouse Life Dependent Child Life Group Universal Life Group Variable Universal Life Survivor Group Policyholder Name Address City State ZIP Phone Number Authorized Group Policyholder Representative (Print) First Name Last Name G685 Page 2 of 2 NW xCA, MI, MN, NV, NY JY2662.SCRE (06/20) Fs/f