To fill out this form, first gather all necessary personal and organizational information beforehand. All forms must be submitted in duplicate.We must receive written application and the first premium for the individual life insurance policy within 31 days after insurance under the Policy ceases. Click on the link(s) for the forms you'd like to download. I. The February 3, 2022 notice of action issued to Ms. Shell denying her application for longterm care Medicaid is defective. Employees separated from City employment have the option to convert their life insurance policy from a City paid premium to a personally paid.