_________________________, 20___
							(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 2006
This is not a substitute for legal advice.  An attorney must be consulted.