Form

LifeX VL Benefit Plan

NETWORK CONVERSION FORM
Research Associate Name:*
Research Associate ID:*
Please note that you have the option to CONVERT your current VL Benefit Plan Network to PHCS effective for 12/01/2025.

PLAN NETWORK SECTION
IMPORTANT NOTICE:

This form MUST be completed and sent in by 11/15/2025 to have your Benefit Plan EFFECTIVE for 12/01/2025.
Please Select:*

Convert Benefit Plan to PHCS Network
Please Select:*

Effective Date of 12/01/2025

LifeX VL Benefit Plan