5-Star Policy Conversion Form - Porting Your Policy

Policy Conversion Form

Please fill out the below completely to Port your policies
PLEASE COMPLETE THE BELOW IN IT'S ENTIRETY TO PREVENT ANY DELAYS WITH YOUR REQUEST:
First Name*
Middle Name
Last Name*
Phone Number*
Email*
example@example.com
Address*

Street Address, Include Suite # or Apartment if applicable

Street Address Line 2

CityState

ZIP Code
Please Select the eligible products that you wish to port (Self-Pay):*

Assurity5-Star
Monthly Premium - 5Star Life Insurance Policy*
Example: $56.24
AUTOMATIC BANK PAYMENT AUTHORIZATION
Automatic bank withdrawal allows you to pay your premium and/or loan from your checking or savings account, saving you time and money. To begin this convenient service, or to make changes to your existing payment plan, please complete the form below.

AUTOMATIC BANK WITHDRAWAL AUTHORIZATION

I/we hereby authorize 5Star to initiate debit entries, electronically, by paper means, or by other commercially accepted method to my/our checking account designated in this authorization. This authorization is to remain in full force until 5Star has received notification from me/either of us of its termination at least two business days prior to the regularly scheduled draft day. I/we agree that 5Star shall be fully protected in making any such debit entry if 5Star does not receive sufficient notification to discontinue this agreement.
Start New Bank Withdrawl

Yes
Monthly Bank Withdrawal Date - Choose from the 1st to the 28th for your monthly bank draft (Cannot be 29, 30 or 31)*
Name of Financial Institution*
Routing No - 9 digit number*
Account No*
Name of Account Holder*
TO ENSURE ACCURACY, SUBMIT VOIDED CHECK
Upload Voided Check or Bank Deposit Slip

Cancelof
Today's Date:*

MonthDayYear
Date
Signature of Insured*

Clear
PLEASE DO NOT CLOSE YOUR BROWSER AFTER SUBMITTING THIS FORM

YOU WILL BE REDIRECTED TO THE POLICY CONVERSION FORM FOR YOUR ASSURITY POLICIES
Should be Empty:

Policy Conversion Form

AUTOMATIC BANK PAYMENT AUTHORIZATION

TO ENSURE ACCURACY, SUBMIT VOIDED CHECK