0000187-0000001-0000015

46835/46907/ 1018/47255

epsmoore_awhonn-ny-46835-disability

Please Choose the Plan - check one:

qPlan I: 5 Year Benefit Period

qPlan II: To Age 65 Benefit Period

HARTFORD LIFE INSURANCE COMPANY

Simsbury, CT 06089

0000188-0000001-0000015

*00930001000*

0000189-0000001-0000015

Send this completed form to:

ADMINISTRATOR

AWHONN GROUP INSURANCE PROGRAM

P.O. BOX 10374

Des Moines, IA 50306

QUESTIONS?

Call: 1-800-503-9230

www.personal-plans.com/awhonn

0000190-0000001-0000015

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*00940001000*

0000191-0000001-0000015

0000192-0000001-0000015

THIS PAGE IS INTENTIONALLY LEFT BLANK.

*00950001000*

0000193-0000001-0000015

0000194-0000001-0000015

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*00960001000*

0000195-0000001-0000015

0000196-0000001-0000015

*00970001000*

0000197-0000001-0000015

Marsh U.S. Consumer,

a Service of Seabury & Smith, Inc.

P.O. Box 10374

Des Moines, IA 50306-0374

Administered by:

P.O. Box 10374

Des Moines, IA 50306-0374

1-800-503-9230

http://www.personal-plans.com/awhonn

AR Ins. Lic. #245544

CA Ins. Lic. #0633005

d/b/a in CA Seabury & Smith Insurance Program

Management

Underwritten by:

Hartford Life Insurance Company

Simsbury, CT 06089

0000198-0000001-0000015

*00980001000*