Life Insurance Conversion Form

Fill out the Application to Convert Group Life Insurance form and send it BCBSIL/Dearborn within 31 days after the Date of Loss that appears on your COBRA election form. 

The Fund has already completed the Employer section for you. You just need to fill out the rest of the form and include your payment based on how much insurance you want and whether you want to pay premiums monthly, quarterly or annually. 

You can choose to have the same amount of insurance you had with the Fund or a smaller amount.  The amount you choose must be a multiple of 1,000.  If you can’t figure out how to fill in the row that begins “Amount of Insurance,” you can leave that row blank and submit the form anyway within the 31-day deadline. BCBSIL/Dearborn will send you back a letter explaining how much your premium is and the deadline for sending it.  You can always call BCBSIL/Dearborn with questions at (800) 367-6401.

Download Life Insurance Conversion Form