Individual life insurance coverage
after your group coverage ends
Symetra Group Life Insurance Conversion Kit
LDM-6233 6/16
Symetra Group Life Insurance Conversion Kit
This feature, called “conversion,” allows you to easily convert your Symetra Group Life
Insurance Policy to an individual life insurance policy offered through HRMP and insured
by Gerber Life Insurance Company. You can also convert any eligible spouse and
dependent coverage.
Converting your Symetra Group Life Insurance policy lets you maintain your current
level of life insurance coverage without having to answer additional health questions or
go through any type of medical exam.
Getting Started
To apply for conversion to an individual life insurance policy, fill out the enclosed
Request for Information Form. This must be completed for any coverage you wish to
convert for you, your spouse and/or your dependents.
It’s important to get started as soon as possible. HRMP must receive your Request for
Information Form within 31 days after the date your group life insurance ends.
Your group life insurance coverage—provided by
Symetra Life Insurance Company—allows you to
keep your life insurance coverage on an individual
basis after your group life insurance coverage ends.
Contact Information
HRMP
Toll-free: 1-888-999-4767
Local: (978) 762-0661
Fax: (978) 762-4767
Monday–Friday
7:30 a.m. to 5:00 p.m. ET
Symetra Group Life Insurance Conversion Kit
Frequently Asked Questions
Do I need a medical exam?
No. A medical exam is not required, and you
will not have to answer any health questions.
How much does it cost?
The actual cost (rate) is determined by your
age, gender, the amount of life insurance
coverage you elect and other factors. You
can estimate your new life insurance rates
using our online calculator located at
www.symetralifeconv.com. Enter your
information as directed, then fill out the
enclosed Request for Information Form.
Rates are also included in the mailing that
HRMP sends once they receive the Request
for Information Form.
Can I choose what kind of individual life
insurance policy I want?
You can only convert your existing Symetra
Group Life Insurance policy to an individual
whole life insurance policy.
1
How long will it take to get coverage?
Your HRMP representative will respond to you
by U.S. Mail (or by email if your email address
is provided) within two days of submitting your
completed request for conversion. If you elect
to convert, you must return your completed
application and initial premium within the 31-day
conversion period.
Your conversion policy will be effective on the
day after your 31-day conversion period ends.
Will I have life insurance coverage during
the conversion process period?
Yes. Your group insurance benefits remain in
effect during your 31-day conversion period.
Does my employer need to submit
anything?
Yes. The Request for Information Form has
two parts—A and B. Your employer needs to
complete Part A and you will complete Part B.
Your HRMP representative will go over what
exactly is required when you call to apply.
To learn more about conversion,
call HRMP at 1-888-999-4767 or
visit www.symetralifeconv.com.
Group insurance policies are insured by Symetra Life Insurance Company, 777 108th Avenue NE,
Suite 1200, Bellevue, WA, 98004 and are not available in any U.S. territory. Policies may be subject to
exclusions, limitations, reductions and termination of benefit provisions. Our New York Company insures
products for New York policyholders. Please contact your representative for complete details.
Individual life insurance offered through the Symetra Group Life Insurance Conversion provision is offered
through HRMP and insured by Gerber Life Insurance Company; not affiliated with any of the subsidiaries
under Symetra Financial Corporation.
1
May vary by state. In West Virginia, you may purchase preliminary term for one year which will automatically convert to whole
life thereafter.
Symetra Life Insurance Company
777 108th Avenue NE, Suite 1200
Bellevue, WA 98004-5135
www.symetra.com
Symetra
®
is a registered service mark of
Symetra Life Insurance Company.
Getting
Started
Don’t miss the deadline to
convert your group life insurance
coverage. Complete your Request
for Information Form today.
Call HRMP at 1-888-999-4767
if you have any questions.
LG-12204 3/15 Symetra
®
is a registered service mark of Symetra Life Insurance Company.
INDIVIDUAL LIFE CONVERSION
Request for Information Form
This form enables you and your insured dependents to obtain information on any right you may have to purchase an individual life insurance policy within 31 days after
your Symetra Group Life coverage ends or is reduced because of termination of employment or change in your classification or status in the eligible member group.
Please complete the information below, if you are interested, and an application and premium costs will be sent. Your Request for Information Form needs to be
submitted to this office within 31 days after the date of your Symetra Group Life Insurance ending. Please review the Conversion Right provision in your existing
Certificate (or if unavailable contact the Policyholder/Plan Administrator) to ensure an understanding of your conversion rights, responsibilities and any
extension to convert that may be available in your state.
PART A - POLICYHOLDER OR ADMINISTRATOR TO CERTIFY
Name of Employee/Member
Symetra Life Insurance Company
Name of Policyholder (use name shown in group policy or booklet)
Policy#
Policyholder's address
Contact name
DATE OF GROUP LIFE INSURANCE TERMINATION
/ /
LAST DATE WORKED
/ /
TOTAL AMOUNT OF GROUP LIFE INSURANCE ON TERMINATION DATE
Basic $ _____________________ Supplemental $ ___________________
Employee/Member's Occupation_______________________________________________ Class__________________ Annual Salary_______________________
Employee/Member's Hire Date_____/_____/_______ Employee/Member's effective date of Symetra Group Life Insurance Coverage under the Group Policy____/____/_____
Did Employee/Member have Dependent Life Insurance on Group Plan?
Yes No
Amount of Spouse Life Insurance $______________________ Amount of Child Life Insurance $___________________________
REASON FOR TERMINATION:
EMPLOYEE/MEMBER DEPENDENT
Termination of Policy Termination of Policy
Termination of Employment Divorce
Disability Marriage of a child
Other (please explain)__________________ A surviving spouse or child of deceased employee/member
_______________________________________
Other (please explain)__________________
_______________________________________
Is Employee/Member Disabled?
Yes No
Is Employee/Member on Disability?
Yes No If Yes, did he/she become disabled prior to age 60? Yes No
Has the insured Employee/Member made an Absolute Assignment of the group life insurance to be converted?
Yes No
If yes, please attach a copy of the Absolute Assignment form.
Date on which this Notice was given to Employee/Member _______/________/________
Date Notice completed
/ /
Signature of Policyholder/Plan Administrator Title Phone number
( )
PART B - TO BE COMPLETED BY EMPLOYEE/MEMBER REQUESTING CONVERSION INFORMATION
Name
Soc Sec # Date of birth
/ /
Age
Sex
Home address
Street City State Zip code
Phone # ( ) Email
If Spouse or Children are checked above, provide information below:
Name of dependent(s) Age Date of birth Soc Sec # Sex Relationship to you
/ /
/ /
/ /
Employee/Member's signature ______________________________________________________ Date completed and mailed_______/________/________
Mail to: HRMP Life Conversion Facility, 300 Rosewood Drive, Suite 250, Danvers, MA 01923
Toll Free: 1-888-999-4767 Phone: (978) 762-0661 Fax: (978) 762-4767 Email: [email protected]
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