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(Date of Letter)

(Insurance Company Name) (Policy Administrator) (Street Address) (City, State and Zip Code) RE: (Name of Insured) (Claim Number) (Date of Loss) (Conversion Rights)

Dear Policy Administrator: It is the understanding of the undersigned that the above-referenced policy presently provides insurance coverage for (name of insured) through (identify name of group plan). Due to circumstances that have recently developed involving the participation in the plan by (name of individual whose circumstances have changed), it may be necessary for the above-referenced policy conversion to occur, pursuant to provisions of the policy and (name of state) law. Accordingly, all appropriate information and forms relating to the conversion rights for the policy are requested. Since the conversion of the aforementioned policy is a timely matter, the appropriate directives, rules, regulations, guidelines and forms that would apply to the conversion of the above-referenced policy will need to be received and processed as rapidly as possible. Therefore, kindly provide the undersigned, on behalf of (name of insured, insured's family member or household member), appropriate documentation, notices, etc., all pursuant to the foregoing request. Your early response will be appreciated. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number) LAWCHEK, LTD. LETTER PRO Samples, Copyright 2000 This is not a substitute for legal advice. An attorney must be consulted.