Issuance of a converted policy shall be subject to the following conditions:
(1) Written application for the converted policy shall be made and the first premium paid to the insurer not later than thirty-one (31) days after the termination under the group policy;
(2) The converted policy shall be issued without evidence of insurability;
(3) The initial premium for the converted policy for the first twelve (12) months and subsequent renewal premiums shall be determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of each person to be covered under the converted policy and to the type and amount of insurance provided;
(4) The effective date of the converted policy shall be the day following the termination of insurance under the group policy; and
(5) The converted policy shall cover the employee or member and the person's dependents who were covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.