| e u l a V _ 1 L V S e c n a r u s n I D & D A d n a e f i L l a t n e m e l p p u S - a v f o " e c a l p e R / d n i F " a o d o t e v o b a t x e t e h t s e s u s s e c o r p t s o p A . e r e h x o b t x e t s i h t s i h T . r e d a e h e h t d n a t x e t e l b a i r 4 S F _ p e _ e f i l _ s h B : e t a l p m a T e c n a r u s n I D & D A d n a e f i L l a t n e m e l p p u S : r o f t e e h S t c a F t i f e n e B e u n e v e R f o t n e m t r a p e D a d i r o l F k e e w r e p s r u o h 0 3 t s a e l t a s k r o w o h w e e y o l p m e e m i t l l u f e v i t c a n a e r a u o y f i e l b i g i l e e r a u o Y . s i s a b d e l u d e h c s y l r a l u g e r a n o y t i l i b i g i l E l l i w e s a c o n n I . y c i l o p e h t f o s n o i t i d n o c d n a s m r e t e h t o t t c e j b u s t c e f f e o t n i s e o g e g a r e v o C n a h t r e n o o s e v i t c e f f e e m o c e b s t fi e n e b d e t c e l e y l w e n 3 1 0 2 / 1 / 8 r o e r i h f o e t a d e h t n o t s u m u o Y . . t c e f f e s e k a t e g a r e v o c r u o y y a d e h t n o r e y o l p m e r u o y h t i w k r o W t a y l e v i t c A e b e t a D e v i t c e f f E e g a r e v o C 3 1 0 2 / 1 / 6 h g u o r h t 3 1 0 2 / 1 3 / 7 d o i r e P t n e m l l o r n E e s a h c r u p n a c u o Y e c n a r u s n I D & D A d n a e f i L l a t n e m e l p p u S f o s t n e m e r c n i n i 0 0 0 , 0 1 $ . n a h t e r o m e b t o n n a c e s a h c r u p n a c u o y t n u o m a m u m i x a m e h T f o r e s s e l e h t 5 r u o y s e m i t l a u n n a y r a l a S r o 0 0 0 , 0 0 3 $ . l a u n n A y r a l a S s i r u o y h t i w t c a r t n o c s ’ d r o f t r a H e h T n i d e n i f e d s a . r e y o l p m e t n u o m A t i f e n e B s e i r u j n i d e r e v o c e h T . t n e d i c c a n a m o r f h t a e d r o s e i r u j n i n i a t r e c o t e u d s t fi e n e b s e d i v o r p D & D A : s y a p e c n a r u s n i e h T . t n e d i c c a t a h t r e t f a s y a d 5 6 3 o t p u r u c c o n a c h t a e d r o • , e f i l f o s s o l l a t n e d i c c a f o t n e v e e h t n i e s a h c r u p u o y e g a r e v o c f o t n u o m a e h t f o % 0 0 1 d n a h c e e p s r o , e y e e n o f o t h g i s e h t d n a b m i l e n o , s e y e h t o b f o t h g i s e h t , s b m i l o w t . a i g e l p i r d a u q r o s r a e h t o b n i g n i r a e h • . ) s b m i l e e r h t f o s i s y l a r a p ( a i g e l p i r t r o a i g e l p a r a p r o f % 5 7 • g n i r a e h r o h c e e p s r o , e y e e n o f o t h g i s , b m i l e n o f o s s o l l a t n e d i c c a r o f ) % 0 5 ( f l a h - e n O . a i g e l p i m e h r o s r a e h t o b n i • r o d n a h e m a s e h t f o r e g n fi x e d n i d n a b m u h t f o s s o l l a t n e d i c c a r o f ) % 5 2 ( r e t r a u q - e n O . a i g e l p i n u e h t f o % 0 0 1 n a h t e r o m e b t o n l l i w t n e d i c c a e m a s e h t o t e u d s e s s o l l l a r o f t fi e n e b l a t o t r u o Y . e s a h c r u p u o y e g a r e v o c f o t n u o m a e g a r e v o C D & D A d e fi i l p m i S e h t e t e l p m o c t s u m u o y e g a r e v o c g n i t s i x e r u o y g n i s a e r c n i r o w e n g n i t c e l e e r a u o y f I r o , d e v o r p p a e b l l i w e g a r e v o C . t n e m l l o r n e s i h t g n i r u d m r o F ) U M S ( g n i t i r w r e d n U l a c i d e M t n u o m a w e n a t c e l e u o y f I . s e s n o p s e r r u o y n o d e s a b d e t s e u q e r e b l l i w n o i t a m r o f n i l a n o i t i d d a f o t n u o m a e u s s i d e e t n a r a u g e h t s d e e c x e t a h t 0 0 0 , 0 8 $ l a n o i t i d d a e d i v o r p o t d e e n l l i w u o y , e m o c e b n a c s s e c x e e h t e r o f e b d r o f t r a H e h T o t y r o t c a f s i t a s s i t a h t h t l a e h d o o g f o e c n e d i v e . e v i t c e f f e t n u o m A e u s s I d e e t n a r a u G 0 7 e g a t a % 0 5 . t n e m e r i t e r t a s l e c n a c e g a r e v o c l l A . s n o i t c u d e R t i f e n e B 0 - 7 2 8 8 3 e g a P 1 f o 2 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Offce of both companies: Simsbury, CT. All benefts are subject to the terms and conditions of the policy. Policies i i underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policies may be continued in force or discontinued i . Florida Department of Revenue ) A L H ( y n a p m o C e c n a r u s n I t n e d i c c A d n a e f i L d r o f t r a H d o i r e P t n e m l l o r n E 3 1 0 2 / 1 / 6 - 3 1 0 2 / 1 3 / 7 Rev 03/08
Transcript
|eulaV_1LVS ecnarusnI D&DA dna efiL latnemelppuS
-av fo "ecalpeR/dniF" a od ot evoba txet eht sesu ssecorp tsop A .ereh xob txet siht sihT .redaeh eht dna txet elbair
4SF_pe_efil_shB :etalpmaT
ecnarusnI D&DA dna efiL latnemelppuS
:rof teehS tcaF tifeneB
euneveR fo tnemtrapeD adirolF
keew rep sruoh 03 tsael ta skrow ohw eeyolpme emit lluf evitca na era uoy fi elbigile era uoY .sisab deludehcs ylraluger a no
ytilibigilE
lliw esac on nI .ycilop eht fo snoitidnoc dna smret eht ot tcejbus tceffe otni seog egarevoC naht renoos evitceffe emoceb stfieneb detcele ylwen 3102/1/8 ro erih fo etad eht no tsum uoY .
.tceffe sekat egarevoc ruoy yad eht no reyolpme ruoy htiw kroW ta ylevitcA eb
etaD evitceffE egarevoC
3102/1/6 hguorht 3102/13/7 doireP tnemllornE
esahcrup nac uoY ecnarusnI D&DA dna efiL latnemelppuS fo stnemercni ni 000,01$ .
tnuoma wen a tcele uoy fI .sesnopser ruoy no desab detseuqer eb lliw noitamrofni lanoitidda fo tnuoma eussi deetnaraug eht sdeecxe taht 000,08$ lanoitidda edivorp ot deen lliw uoy ,
emoceb nac ssecxe eht erofeb droftraH ehT ot yrotcafsitas si taht htlaeh doog fo ecnedive .evitceffe
tnuomA eussI deetnarauG
07 ega ta %05 .tnemeriter ta slecnac egarevoc llA .
snoitcudeR tifeneB
0-72883 egaP 1 fo 2
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts are subject to the terms and conditions of the policy. Policiesii underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policies may be continued in force or discontinuedi .
Florida Department of Revenue )ALH( ynapmoC ecnarusnI tnediccA dna efiL droftraH doireP tnemllornE 3102/1/6 - 3102/13/7
Rev 03/08
tcele uoy fI ecnarusnI D&DA dna efiL latnemelppuS y ,flesruoy rof esahcrup ot esoohc yam uo ecnarusnI efiL latnemelppuS esuopS fo stnemercni ni 000,5$ fo mumixam a ot , 000,051$ .
egarevoc ecnarusnI . esuopS ruoy rof egarevoc tcele ton yam uoY rebmem evitca na era yeht fi na sa derevoc ydaerla si ro ,ytirohtua lanoitanretni ro yrtnuoc yna fo secrof demra eht fo
rieht no desab detseuqer eb lliw noitamrofni lanoitidda ro ,devorppa eb lliw egarevoC fo tnuoma eussi deetnaraug eht sdeecxe taht tnuoma na tcele uoy fI .sesnopser 000,03$ ruoy ,
esuopS ehT ot yrotcafsitas si taht htlaeh doog fo ecnedive lanoitidda edivorp ot deen lliw .evitceffe emoceb nac ssecxe eht erofeb droftraH
efiL latnemelppuS esuopS ecnarusnI
tcele uoy fI ecnarusnI D&DA dna efiL latnemelppuS - flesruoy rof uoY esahcrup ot esoohc yam ecnarusnI efiL latnemelppuS )ner(dlihC egarevoc fo stnemercni ni 000,2$ fo mumixam a ot
000,01$ –dlihC hcae rof deriuqer si noitamrofni lacidem on . rof egarevoc tcele ton yam uoY lanoitanretni ro yrtnuoc yna fo secrof demra eht fo rebmem evitca na si dlihC ruoy fi dlihC ruoy
.ytirohtua
• morf derevoc era dna deirramnu eb tsum )ner(dlihC syad 51 ot 91 dlo sraey ro 52 fi sraey .snoitidnoc rehto niatrec teem ro tneduts emit-lluf a era yeht
• ega revo )ner(dlihC deirramnU 91 yliramirp dna delbasid era yeht fi derevoc eb yam .troppus laicnanif rof eeyolpmE eht nopu tnedneped
• morf )ner(dlihC syad 51 ot shtnom 6 fo tifeneb decuder a ot detimil era 001$ .
a htiw ssenlli lanimret a gnivah sa desongaid era uoy fI 21 gniviL eht ,ycnatcepxe efil htnom efil ruoy fo noitrop a fo tnemyap detarelecca na eviecer ot uoy swolla noitpO stfieneB
morf egarevoc puorg ni 000,01$ tsael ta htiw slaudividni ot elbaliava si noitpo ehT .ecnarusnI fo timil ega mumixam a ot tcejbus si dna droftraH ehT 06 muminim a tseuqer yam uoY .
deecxe ot ton egarevoc ruoy fo %08 fo mumixam a ot pu 000,3$ fo tnemyap detarelecca 000,003$ ehT .meht esu uoy woh no snoitcirtser ycilop on htiw ,uoy ot yltcerid diap era sdnuF .
.yraicfieneb ruoy ot elbayap neht si tfieneb gniniamer
noitpO stifeneB gniviL
erofeb delbasid yllatot emoceb uoy fi seilppa noisivorp sihT 06 ta rof stsal ytilibasid ruoy dna tsael 9 fo yad tsal ruoy fo raey eno nihtiw noitidnoc ruoy fo foorp edivorp tsum uoY .shtnom
ot pu muimerp fo tnemyap tuohtiw eunitnoc lliw egarevoc ruoy ,evorppa ew ecno dna krow egA tnemeriteR lamroN ytiruceS laicoS .delbasid yllatot niamer uoy sa gnol sa , muimerp ehT
reviaw rof devorppa dna delbasid era uoy fi deviaw eb osla lliw egarevoc s’tnedneped ruoy rof .setanimret ycilop eht fi dne lliw stnedneped ruoy rof egarevoC .muimerp fo fo tnemyaP
.droftraH ehT yb devorppa si reviaw litnu deriuqer si muimerp
muimerP fo reviaW
snoisulcxE dna snoitatimiL
.sraey owt rof derusni neeb sah eeyolpme eht retfa ylno derevoc si edicius yb htaed ,snalp ecnarusnI efil mret tsom htiw dradnats si sA eht fo sraey owt nihtiw evitceffe emaceb taht egarevoc efiL yna rof elbayap eb lliw tfieneb on ,edicius morf stluser htaed fi ,eroferehT
.tcartnoc a ton si dna ylno sesoprup evitartsulli rof dedivorp si dna dereffo gnieb ecnarusnI eht fo weivrevo na si teehS tcaF tfieneB sihT nac )reyolpme ruoy( redlohycilop eht ot deussi ycilop ecnarusnI eht ylnO .deussi yllautca sa ycilop eht stceffa ro segnahc yaw on ni tI
yna fo tneve eht nI .egarevoc ecnarusnI ruoy fo snoisulcxe dna snoitatimil ,snoitidnoc ,smret ,snoisivorp eht fo lla ebircsed ylluf .ylppa ycilop ecnarusnI eht fo smret eht ,ycilop ecnarusnI eht dna teehS tcaF tfieneB eht neewteb ecnereffid
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts are subject to the terms andii conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policies may be continuedi in force or discontinued.
Florida Department of Revenue )ALH( ynapmoC ecnarusnI tnediccA dna efiL droftraH doireP tnemllornE 3102/1/6 - 3102/13/7
ruoy no desab detseuqer eb lliw noitamrofni lanoitidda ro ,devorppa eb lliw egarevoC .tnemllorne siht gnirud mroF )UMS( gnitirwrednU lacideM fo tnuoma eussi deetnaraug eht sdeecxe taht tnuoma wen a tcele uoy fI .sesnopser 000,08$ fo ecnedive lanoitidda edivorp ot deen lliw uoy ,
.evitceffe emoceb nac ssecxe eht erofeb droftraH ehT ot yrotcafsitas si taht htlaeh doog
ruoy etaluclac oT ylhtnoM :)s(alumrof gniwollof eht esu esaelp ,tsoc
ot tcele I esahcrup efiL fo ________________$ D&DA dna .egarevoc I enilced efiL esahcrup ot D&DA dna .egarevoc I ot tcele eunitnoc efiL tnerruc ym D&DA dna .egarevoc
ecnarusnI efiL latnemelppuS esuopS esahcrup uoy fI ecnarusnI D&DA dna efiL latnemelppuS uoy , esahcrup nac ecnarusnI efiL latnemelppuS esuopS fo stnemercni ni 000,5$ . ehT
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts are subject to theii terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policiesi may be continued in force or discontinued. Florida Department of Revenue
eno naht erom eman uoy fI .gninaem ruoy ot sa noitseuq on eb lliw ereht taht os raelc si noitangised yraicfieneb ruoy erus ekam esaelP edivorp esaelP .yraicfieneb hcae ot diap eb ot tfieneb ruoy fo egatnecrep eht wohs ,yraicfieneb tnegnitnoc ro yramirp lla noitamrofni eht fo
fI .pihsnoitaler detats rieht sa ”detaleR toN“ ,sdrow eht tresni ,egairram yb ro doolb yb rehtie detaler ton si yraicfieneb ruoy fI .woleb detseuqer .rosivda lagel nwo ruoy ro rotartsinimda stfieneb ruoy tcatnoc ,ecnatsissa deen uoy
2 0-72883
egaP 2 fo 5
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts are subject to theii terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policiesi may be continued in force or discontinued. Florida Department of Revenue
noitamrfinoC eht ni llorne ot ytinutroppo eht nevig neeb evah I taht egdelwonkca I efiL dna steehS thgilhgiH tfieneB eht ni debircsed egarevoc ecnarusnI
hguorht dereffo euneveR fo tnemtrapeD adirolF .
si taht ytilibarusni fo ecnedive edivorp ot deriuqer eb lliw I ,llorne ot ediced retal tub ,won egarevoc enilced I fi taht eerga dna dnatsrednu I eb yam egarevoc rof tseuqer ym dnatsrednu I .evitceffe semoceb ti erofeb egarevoc hcus rof devorppa eb dna droftraH ehT ot yrotcafsitas
.droftraH ehT yb deined
fo snoitidnoc dna smret ,snoisivorp eht htiw ecnadrocca ni ylno tceffe ni niamer dna tceffe otni og lliw ecnarusni taht eerga dna dnatsrednu I eht ebircsed ylluf nac )reyolpme ruoy( redlohycilop eht ot deussi ycilop ecnarusni eht ylno taht eerga dna dnatsrednu I .ycilop ecnarusni eht
mrof tnemllorne eht neewteb ecnereffid yna fo tneve eht nI .egarevoc ecnarusni ruoy fo snoisulcxe dna snoitatimil ,snoitidnoc ,smret ,snoisivorp .ycilop ecnarusni eht yb dnuob eb ot eerga I ,ycilop ecnarusni eht dna
ni detats ega defiiceps a ta decuder si tfieneb ecnarusni efil ym taht eerga dna dnatsrednu I ,droftraH ehT htiw egarevoc ecnarusni efil evah I fI
lliw elbayap era stfieneb noitarud mumixam eht taht eerga dna dnatsrednu I ,droftraH ehT htiw egarevoc emocni ytilibasid evah I fI .ycilop eht .noitidnoc gnitsixe-erp a rof devorppa eb ton yam stfieneb rof mialc a taht dna ega defiiceps a ta gnitrats doirep defiiceps a ot detimil eb
.sgninrae ym morf snoitcuded lloryap etairporppa eht ekam ot reyolpme ym ezirohtua I
ym ot deussi sa ycilop puorg eht fo smret eht htiw ecnadrocca ni elbigile ton ma I fi ecrof ni ro dilav eb lliw ecnarusni on taht dnatsrednu I
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts are subject to theii terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policiesi may be continued in force or discontinued. Florida Department of Revenue
Generic EP Full Language
PA 9199
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts areii subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms underi which the policies may be continued in force or discontinued.
Florida Department of Revenue SMU
Rev 03/07
cireneg_umS :etalpmeT
noitacilppA gnitirwrednU lacideM defiilpmiS
Name:_____________________
S’ESUOPS ERUTANGIS rof gniylppa fi ylno deriuqeR(
)egarevoC efiLot evitatneserper lageL ro
esuopS
ETAD DENGIS
:pihsnoitaleR ________
ERUTANGIS S’EEYOLPME )deriuqeR(
ot evitatneserper lageL ro tnacilppA
ETAD DENGIS
:pihsnoitaleR ________
ynapmoC ecnarusnI tnediccA dna efiL droftraH
.xob detangised eht ni on ro sey gnikcehc yb snoitseuq gniwollof eht rewsna esaelP
?egarevoc ecnarusni efil yna rof denilced neeb )egarevoc rof desoporp enoyna ro( uoy evah ,sraey 5 tsap eht gniruD eeyolpmE seY oN esuopS � seY � oN
ECITONtsap eht gninrecnoc feileb dna egdelwonk ym fo tseb eht ot eurt dna etelpmoc era srewsna evoba eht taht yfitrec ybereh I
tnemucod siht taht eerga I .etaler srewsna eht mohw ot )s(nosrep eht fo yrotsih lacidem dna htlaeh fo etats tneserp dna .stfieneb puorg rof tseuqer tnemllorne ym fo trap a mrof llahs stnetnoc sti lla dna
eslaf stneserp ylgniwonk ro tfieneb ro ssol a fo tnemyap rof mialc tneluduarf ro eslaf a stneserp ylgniwonk ohw nosrep ynA
sihT .nosirp ni tnemenfinoc dna senfi ot tcejbus eb yam dna emirc a fo ytliug si ecnarusni rof noitacilppa na ni noitamrofni ediced ot sesoprup noitartsinimda nalp rof ynapmoC ecnarusnI tnediccA dna efiL droftraH eht yb desu eb yam noitamrofni
.egarevoc rof elbigile era/si )s(nosrep eht fi
euneveR fo tnemtrapeD adirolF
PA 9199
:egap tsrfi eht no dnopser dna egaugnal yrotutats cfiiceps eht daer esaelp ,setats gniwollof eht fo stnediser roF
depoleved ton evah uoy fi VIH rof detset neeb evah uoy rehtehw esolcsid ot deriuqer ton era uoy ,noitseuq ).noitseuq siht ot esnopser ni CRA ro SDIA esaesid eht fo smotpmys
DEEN UOY :ETON ?)CRA( xelpmoC detaleR-SDIA ro )SDIA( emordnyS ycneicfieD enummI deriuqcA ro ;esaesid revil ro RO REDNEFFO LANIMIRC A OT )1( :DERETSINIMDA SAW HCIHW TSET )SURIV SDIA( VIH NA ESOLCSID TON OHW TNEITAP A OT )2( ;ECILOP EHT OT DETROPER SAW TAHT EMIRC A FO TLUSER A SA MITCIV LANIMIRC LACIDEM RO LATIPSOH A TA LENNOSREP SECIVRES LACIDEM YCNEGREME FO SECIVRES EHT DEVIECER
GNIMROFREP FO TLUSER A SA DETSET EREW OHW LENNOSREP LACIDEM YCNEGREME OT )3( ;YTILICAF ERAC .SECIVRES LACIDEM YCNEGREME
?naicisyhp lacidem desnecil a yb )CRA( xelpmoC detaleR-SDIA ro
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef ts areii subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms underi which the policies may be continued in force or discontinued.
Florida Department of Revenue SMU
Rev 03/07
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. PA-9199 (Rev. 3/07) 1 of 5
PERSONAL HEALTH APPLICATION
Thank you for choosing The Hartford. All sections of this form must be completed and received by The Hartford within 30 days of the signature date. Employers: Please completely fill out Section 1 and Section 2 on this page and forward the entire form to the employee. Refer to your Policy and employee records for this information. These records are your property and are not on file with The Hartford. An incomplete form will result in a delay in processing your employee’s request for insurance.
Section 1: Employer Details (to be completed by Employer) PLEASE PRINT CLEARLY
Employer Name: Policy Number:
Division (if applicable):
Employer Mailing Address (Street, City, State, Zip Code):
Section 2: Employee Details (to be completed by Employer) PLEASE PRINT CLEARLY Employee Name (First, MI, Last):
Base Annual Earnings*: Social Security Number: - - Date of Hire (mm/dd/yyyy): / / * Base annual earnings as described in the contract with The Hartford. Coverage Details • Check the applicable box(es) in each row to reflect the applicant’s current coverage and new election. • Enter the amount of any existing coverage (including Guarantee Issue (GI)**) in Current Coverage. Please include the current
amount of Basic Life coverage even if the applicant is not requesting Basic Life coverage at this time. • Enter the amount of Additional Coverage Requested that requires medical underwriting. • Enter the Total Coverage Amount that will be in force if the additional coverage requested is approved. • If the applicant is enrolling after his/her initial eligibility period and does not have current coverage they will be responsible for
all fees incurred during the medical underwriting process.
Current Coverage (including GI Amount)
Additional Coverage Requested
Total Coverage Amount
Life Insurance Coverage Enter all amounts as dollars. Include Basic Life Current Coverage Amount even if not requesting this coverage type.
Employee Basic Life $ $ $ Employee Supplemental or Voluntary Life $ $ $ Spouse Basic Life $ $ $ Spouse Supplemental or Voluntary Life $ $ $
** Guarantee Issue (GI) is the maximum amount of coverage, as defined in the contract with The Hartford, which does not require evidence of good health.
Employees: Please complete pages 2 thru 5. It should take you about 10 minutes to complete this form.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. PA-9199 (Rev. 3/07) 2 of 5
Applicant Section: Please answer all questions on this page completely and accurately and certify your answers on page 4. Leaving information blank will result in delays and may result in your file being closed.
Section 3: Employee Information (Complete even if employee is not applying for coverage) PLEASE PRINT CLEARLY
First Name: Last Name: Social Security # : - - Home Mailing Address (Street, Apt. #): City:
Section 5 – Medical Information (to be completed only by applicants required to provide evidence of good health) If you or anyone proposed for coverage can answer Yes to any of the Questions below, check the appropriate box and provide additional details in Section 6. If you are a resident of one of the following states: Connecticut, Florida, Kentucky, Maine, Maryland, Minnesota, New York, North Carolina, Vermont, or Wisconsin then please go to the State Variable Question section on page 3 and answer or review the appropriate question for your state. After you have read that information, proceed with completing this section. 1. Within the past 5 years, with the exception of a past pregnancy, have you lost time from work for more than
10 work days for the same physical, mental, or emotional condition, disability, injury, or sickness? Employee Spouse
2. Within the past 5 years, have you used any controlled substances, with the exception of those prescribed by your physician, received medical advice or sought treatment for drug or alcohol abuse, or been charged with operating a motor vehicle under the influence of drugs or alcohol?
Employee Spouse
3. Are you currently undergoing any diagnostic testing for symptoms without a final diagnosis or resolution? Employee Spouse
4. Are you currently pregnant? If yes, what was your pre-pregnancy weight?_________ lbs. Employee Spouse
5. During the past 5 years have you been diagnosed with or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other immune deficiency disorder?
Employee Spouse
6. During the past 5 years have you been diagnosed with, treated for, treated with, or had any symptoms due to any of the following conditions or treatments listed below? Please check all that apply:
Employee Spouse Employee Spouse Heart-Related Surgery or Heart Attack Crohn’s Disease Stroke Kidney Failure/Dialysis Heart Disease (excluding high blood pressure & heart murmur) Hepatitis (excluding Hepatitis A)
Blocked Arteries (including arteriosclerosis, atherosclerosis, aneurysm, or deep vein blood clot)
Diabetes
Chronic Obstructive Pulmonary Disorder (COPD) Knee Disorder, Injury, or Surgery
Emphysema Back or Neck Disorder, Injury, or Surgery Adjustment Disorder Joint/Ligament Disorder, Injury, or Surgery Bipolar Disorder Osteoporosis or Osteopenia Depression (single episode) Multiple Sclerosis (MS) Depression (multiple episodes) Amyotrophic Lateral Sclerosis (ALS) Psychotic/Personality Disorders Muscular Dystrophy Other Mental/Nervous/Psychiatric Disorders (including Anxiety) Arthritis
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. PA-9199 (Rev. 3/07) 3 of 5
Employee: First Name_____________________________________ Last Name_____________________________________________
Section 5 Continued: State Variable Questions For residents of Connecticut, Florida, Kentucky, Maine, Maryland, Minnesota, New York, North Carolina, Vermont, and Wisconsin review or answer, where applicable, the question listed below instead of the corresponding question listed in the Medical Information section on page 2. Any “Yes” responses can be explained in the Additional Details section of this form. Once you have reviewed/answered these
uestions, please return to Section 5 and proceed with completing the rest of the form. q Information to be Reviewed Florida, Kentucky, and Maryland Residents- Please review this question prior to answering Question 6 in the Medical Information Section on Page 2: Question 6: During the past 5 years have you been diagnosed with, treated for, or treated with any of the following conditions or treatments listed below? Please check all of the conditions on page 2 that apply. Maine Residents- Please review this statement prior to answering the medical questions in Section 5 on Page 2: You are not required to disclose whether you have been tested for HIV, if you have not developed symptoms of the disease AIDS or
RC, in your answer to any of the questions in the Medical Information section. A Minnesota Residents- Please review this statement prior to answering the medical questions in Section 5 on Page 2: You need not disclose an HIV (aids virus) test which was administered: (1) to a criminal offender or criminal victim as a result of a crime that was reported to the police; (2) to a patient who received the services of emergency medical services personnel at a hospital or medical care facility; (3) to emergency medical personnel who were tested as a result of performing emergency medical services. Please review this question prior to answering Question 6 in the Medical Information Section on Page 2: Question 6: During the past 5 years have you been diagnosed by a physician with, treated for, or treated with any of the following onditions or treatments listed below? Please check all of the conditions on page 2 that apply. c
Questions to be Answered Connecticut and Minnesota Residents: Do not answer Question 2 in the Medical Information section. Answer the following question below. Question 2: Within the past 5 years, have you used any controlled substances, with the exception of those prescribed by your physician, received medical advice or sought treatment for drug or alcohol abuse, or been convicted of operating a motor vehicle under the influence of drugs or alcohol? Employee Spouse Florida residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. Question 5: Have you ever tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection or had unexplained weight loss or enlarged lymph nodes?
Employee Spouse New York Residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. Question 5: During the past 5 years have you been diagnosed with or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or any other immune deficiency disorder excluding HIV?
Employee Spouse North Carolina Residents: Do not answer Question 5 in the Medical Information section. Answer the following question below. Question 5: Have you ever been diagnosed or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder? AIDS Related Complex (ARC) is a condition with signs and symptoms which may include generalized lymphadenopathy (swollen lymph nodes), loss of appetite, weight loss, fever, oral thrush, skin rashes, unexplained infections, dementia, depression, or other psychoneurotic disorders with no known cause. “Disorder of the Immune System” includes the hyperimmune conditions, disorders of gammaglobulin synthesis (hypogammaglobulinemia), of white blood cell production and maturation, and the immune-deficiency disorders both congenital and acquired. Also included in disorders of immunity are lupus erythamatosus, Grave’s Disease, rheumatoid arthritis, primary biliary cirrhosis, and others.
Employee Spouse
Vermont Residents: Do not answer Questions 3 or 5 in the Medical Information section. Answer the following questions below. Question 3: Are you currently undergoing any diagnostic testing (excluding prior HIV related testing) for symptoms without a final diagnosis or resolution? Employee Spouse
Question 5: Have you been diagnosed as having or been treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) by a licensed medical physician?
Employee Spouse
Wisconsin Residents: Do not answer Question 3 in the Medical Information section. Answer the following question below. Question 3: Are you currently undergoing any diagnostic testing, excluding AIDS or HIV tests, for symptoms without a final diagnosis or resolution? Employee Spouse
Please proceed with completing the rest of the medical questions on Page 2 once you have completed/reviewed this page.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. PA-9199 (Rev. 3/07) 4 of 5
Employee: First Name_____________________________________ Last Name_____________________________________________
Section 6: Additional Details: If you or anyone proposed for coverage checked any box related to Questions 1 – 6, please provide details in the space below. If you need more space, please attach, sign and date an additional sheet. The Hartford may contact you for additional or missing information.
Question # or Condition Applicant Name Medications/
Treatment Date of
Diagnosis Date of Last
Symptom Current Status of Condition
Physician’s Name, Address, and Phone #
Section 7: Health Question Certification Statement (To be completed by all applicants)
By checking this box: Employee Spouse
I hereby certify that I have reviewed each of the above questions and conditions. I also certify that I have checked all of the questions and conditions that apply to my health history.
Section 8: Authorization (To be reviewed by all applicants) New York Residents: I understand the Medical Information Bureau, Inc. will release records or information only to The Hartford. I authorize The Hartford to give information about me to: its reinsurer(s); the Medical Information Bureau, Inc.; any other insurance company to whom I may apply for Life or Health Insurance; or other persons or organizations handling a claim, underwriting coverage applied for or administering coverage issued as a result of this application; or as required by law.
I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization. This authorization expires 24 months from the date of this application. I understand that a photocopy of this form is as valid as the original and that I have a right to receive a copy of this form upon request.
Residents of All States Except New York: I understand the Medical Information Bureau, Inc. will release records or information only to The Hartford. I authorize The Hartford to give information about me to: its reinsurer(s); the Medical Information Bureau, Inc.; any other insurance company to whom I may apply for Life or Health Insurance; or other persons or organizations handling a claim, underwriting coverage applied for or administering coverage issued as a result of this application; or as required by law.
I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization. This authorization expires 24 months from the effective date of my coverage or, if no coverage has been issued, one (1) year from the date of this application. I understand that a photocopy of this form is as valid as the original and that I have a right to receive a copy of this form upon request.
Additional Language for Maine Residents: This authorization excludes disclosure of the result of a test for HIV if the applicant has not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in this caveat will prohibit this authorization from including the fact that the applicant has AIDS or ARC. I understand that my failure to sign this authorization may impair the ability of The Hartford to process this application or evaluate claims and may be a basis for denying this application or a claim for benefits. Additional Language for Minnesota Residents: This authorization excludes the release of information about HIV (AIDS Virus) tests which were administered (1) to a criminal offender or criminal victim as a result of a crime that was reported to the police; (2) to a patient who received the services of Emergency Medical Services personnel at a hospital or medical care facility; or (3) to emergency medical personnel who were tested as a result of performing emergency medical services. The term “Emergency Medical Personnel” includes individuals employed to provide pre-hospital emergency services; crime lab personnel, correctional guards, including security guards at the Minnesota security hospital, who experience a significant exposure to an inmate who is transported to a facility for emergency medical care; and other persons who render emergency care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical care and would qualify for immunity under the Good Samaritan Law.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies in New York are underwritten by Hartford Life Insurance Company. PA-9199 (Rev. 3/07) 5 of 5
Employee: First Name___________________________________ Last Name____________________________________________ Section 9: Certification (To be reviewed by all applicants) Residents of All States: I hereby certify (“represent” for Kansas residents) that all statements and answers contained herein, are full, complete, and true to the best of my knowledge and belief.
Residents of All States Except New York: I also understand that any misrepresentation contained herein or relied upon by the company may be used to contest the validity of the coverage, within the contestable period if such misrepresentation materially affects acceptance of the risk. This information may be used by The Hartford for plan administration purposes to decide if the person(s) is/are eligible for coverage.
I understand that coverage will not become effective until The Hartford grants it’s underwriting approval. I do not receive temporary or conditional insurance coverage just because I submit an application and pay the first premium.
I agree that this document and all its contents shall form a part of my request for group benefits.
Section 10: Fraud Statement (To be completed by all applicants) Residents of All States Except California, Pennsylvania, and New York: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California Residents: For your protection, California law requires the following to appear on this form: any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a person to criminal and civil penalties.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Notice: To the best of their knowledge, an Applicant is required to notify The Hartford in writing of any changes in any applicant’s medical condition between the date the Applicant signs this form and the date the coverage is approved.
,tsrfi secivres lacidem ycnegreme niatbo esaelp ,ycnegreme lacidem suoires a evah uoy fI
.pu-wollof rof ASU ecnatsissA poruE tcatnoc neht dna
ecnarusnI efiL ym seoD yna edulcni egarevoc ?secivres lanoitidda
dna efiL droftraH dna ynapmoC ecnarusnI efiL droftraH seinapmoc gniussi gnidulcni ,seiraidisbus sti dna .cnI ,puorG secivreS laicnaniF droftraH ehT si ®droftraH ehT stfieneb llA .TC ,yrubsmiS :seinapmoc htob fo ecfifO emoH .ynapmoC ecnarusnI efiL droftraH yb nettirwrednu era kroY weN ni dlos seiciloP .ynapmoC ecnarusnI tnediccA smret dna stfieneb fo noitcuder ,snoitatimil ,snoisulcxe liated evoba detsil seinapmoc gniussi eht yb nettirwrednu seiciloP .ycilop eht fo snoitidnoc dna smret eht ot tcejbus era
.deunitnocsid ro ecrof ni deunitnoc eb yam seicilop eht hcihw rednu 21/20 SN 8024
secivreS lanoitiddA
sliateD tnatropmI
1 detailfifa ton si tserevE .)tserevE( CLL ,egakcaP larenuF tserevE hguorht dereffo era secivreS egreicnoC dna gninnalP larenuF ,puorGeR tserevE htiw noitailfifa on evah setailfifa sti dna tserevE .secivres ecnarusni fo redivorp a ton si dna droftraH ehT htiw
.setailfifa rieht fo yna ro ynapmoC ecnarusnieR tserevE ,.dtL2 ecnadiuGetatsE ® tsissA yraicfieneB dna ® hcysPmoC yb droftraH ehT hguorht dedivorp era secivres ® detailfifa ton si hcysPmoC .
niatrec ro gnitnirp ,tsurt retlehs tiderc revoc ton seod lliw elpmis A .secivres ecnarusni fo redivorp a ton si dna droftraH ehT htiw .uoy ot tsoc lanoitidda na ta elbaliava era serutaef esehT .serutaef rehto
3 detailfifa ton si ecnatsissA poruE .ASU ecnatsissA poruE yb dedivorp era ecnatsissA dna noitcetorP tfehT DI dna ecnatsissA levarT .secivres ecnarusni fo redivorp a ton si dna droftraH ehT htiw
sesoprup evitartsulli rof dedivorp si dna dereffo gnieb secivres ecnarusni-non eht fo weivrevo na si teehS sthgilhgiH tfieneB sihT ylluf nac redivorP ecivreS eht ylnO .dedivorp yllautca sa secivres eht stceffa ro segnahc yaw on ni tI .tcartnoc a ton si dna ylno
