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HomeMy WebLinkAbout2025 STDEmployer Group Benefits Coverage Information Page 1 of 5 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 incomple te 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: Policy Number: Employer Mailing Address (Street, City, State, Zip Code): Division/Location/Subsidiary with Mailing Address (if applicable): Benefits Contact Name (First, Last): Benefits Contact Email Address: Benefits Contact Phone: ( ) - Section 2: Employee Details (to be completed by Employer) PLEASE PRINT CLEARLY Employee Name (First, MI, Last): Date of Hire (mm/dd/yyyy): / / Base Annual Earnings*: Coverage Effective Date* (mm/dd/yyyy): / / * As described in the contract with The Hartford Life Insurance Coverage Requested  Enter the dollar amount of Current Life Coverage, including Guarantee Issue (GI)*. Please include Employee Basic Life coverage even if the employee is not requesting coverage at this time  Enter the dollar amount of Life Coverage Subject to Evidence of Insurability (EOI) * GI is the maximum amount of coverage as defined in the contract with The Hartford that does not require EOI Current Life Coverage, including GI Life Coverage Subject to EOI Employee Basic Life $ $ Employee Supplemental or Voluntary Life $ $ Disability Insurance Coverage Requested  Check Yes if employee is requesting Short Term and/or Long Term Disability coverage that is subject to EOI Short Term Disability ☐ Yes, EOI is required Long Term Disability ☐ Yes, EOI is required The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 (CA) Page 2 of 5 EVIDENCE OF INSURABILITY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY One Hartford Plaza, Hartford, CT 06155 Applicant Information Abbreviations: Employee = EE First Name Last Name Social Security Number Gender Height (ft./in.) Weight (lbs.) If currently pregnant, pre- pregnancy weight Date of Birth (mm/dd/yyyy) (check one) Male Female EE Address: Day Time Phone: Evening Phone: Email Address: Medical Information Each Applicant must answer each of the following questions to the best of their knowledge and belief. EE Within the past 5 years, have you been diagnosed with or treated by a licensed medical physician for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? Yes No Are you currently pregnant? Yes No Within the past 5 years, with the exception of a past pregnancy, have you lost time from work for more than 10 consecutive work days due to a disability, injury, or sickness? Yes No Within the past 5 years, have you used any controlled substances, with the exception of those taken as prescribed by your physician, been diagnosed or treated for drug or alcohol abuse (excluding support groups), or been convicted of operating a motor vehicle while under the influence of drugs or alcohol? Yes No The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 (CA) Page 3 of 5 Medical Information (continued) Within the past 5 years, have you been diagnosed with or treated by a licensed member of the medical profession for: EE EE Heart Disease (Do not check “Yes” if you only have High Blood Pressure or a Heart Murmur) Yes No Disease, injury or surgery of Joint, Ligaments, Knee, Back, or Neck (including Arthritis) Yes No Heart-Related Surgery or Heart Attack Yes No Muscular Dystrophy Yes No High Blood Pressure If you checked “Yes” to High Blood Pressure, have you had a change in medication within the last 6 months? Yes No Yes No Hepatitis (Do not check “Yes” for Hepatitis A) or Cirrhosis Yes No Blocked Arteries (Arteriosclerosis, Atherosclerosis, Aneurysm, or Deep Vein Blood Clot) Yes No Amyotrophic Lateral Sclerosis (ALS) or Multiple Sclerosis (MS) Yes No Stroke or transient ischemic attack (TIA) Yes No Alzheimer’s or Parkinson’s Disease Yes No Chronic Obstructive Pulmonary Disease (COPD) or Emphysema Yes No Paralysis Yes No Diabetes Yes No Major Organ Transplant Yes No Depression Yes No Chronic Fatigue Syndrome or Fibromyalgia Yes No Sleep Apnea Yes No Narcolepsy Yes No Cancer (Do not check “Yes” for Basal Cell Carcinoma only) If “Yes”, Date of Diagnosis: _______________________________ Yes No Ulcerative Colitis or Crohn’s Disease Yes No Psychotic, Psychiatric, Personality, or Bi-Polar Disorder Yes No Kidney Failure or Dialysis Yes No Notice To the best of your knowledge, you are required to notify Hartford Life and Accident Insurance Company in writing of any changes in your medical condition between the date you sign this form and the date the coverage is approved. In order to complete the evaluation of this application, Hartford Life and Accident Insurance Company may contact you, through the mail or over the telephone: 1. to clarify any information contained on this form; 2. to obtain any information missing from this form; 3. to ask additional questions of you or your physician about the information that you have provided; or 4. to request a paramedical exam. We may also use information about you obtained from other sources, including our claim files, evidence of insurability applications you have previously submitted to us, copies of medical records which you have authorized us to review, and information obtained from MIB, Inc. Only information that is relevant to determining Evidence of Insurability for the coverage which you are currently requesting will be considered. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 (CA) Page 4 of 5 Authorization I, an undersigned applicant, authorize Hartford Life and Accident Insurance Company, together with its affiliates, (“Company”) to contact me, during the evaluation of this application, through the mail, secure e-mail, or over the telephone, at the address or telephone number identified in this application, or otherwise provided by me: 1. to clarify any information contained on this form; 2. to obtain any information missing from this form; or 3. to request a paramedical exam. In the event that I cannot be reached via telephone, I authorize a representative of the Company to leave a voice message identifying his or her name, the Company name, and a return phone number, indicating that he or she is calling to obtain information necessary to complete my recent application for insurance. The message will also contain an underwriting ID number and the hours during which I may reach a representative of the Company by telephone. ❒ Yes, you may leave a message as indicated above. ❒ No, please do not leave a message. In addition to the information that I have provided on this application, I authorize the Company to use information about me obtained from Company claim files, insurance applications and medical information I or my physician(s) have previously submitted to the Company. I further authorize my employer, any health or benefits plan, physician, medical professional, hospital, clinic, laboratory, MIB Group, Inc. (MIB, Inc), pharmacy or pharmacy benefits manager that possesses my protected personal health information (“PHI”), including copies of records concerning physical or mental illness, diagnosis, prognosis, prescription information, care or treatment provided to me (but excluding HIV and genetic testing), to furnish such protected health information to the Company or its representative. The Company may only use information disclosed under this authorization that is relevant to underwrite this or any other insurance application to the Company duri ng the period that the Authorization is valid (as described below), at any time to aid in the detection of fraud, and for internal research purposes. I authorize the Company to disclose the “PHI” in its files to its reinsurer(s) and affiliates, other insurance companies and their affiliates, other persons, representatives and/or organizations performing functions on behalf of the Company and their affiliates, my employer, or as required by law, including any mandated reporting to state agencies. I understand that I may request details about any of the information gathered about me that relates to this application and that such requested information and the identity of the source of the information shall be released to me or, in the case of medical information, to a licensed medical professional of my choice. I/We authorize Hartford Life and Accident Insurance Company, or its reinsurers, to make a brief report of my/our personal health information to Medical Information Bureau. I agree that a photocopy of this authorization is valid as the original and I understand that I or my authorized representative is entitled to receive a copy of this authorization upon request. This authorization shall be valid for twenty-four (24) months from the date signed below. This authorization may be revoked upon written request to the Company, and will not remain valid beyond the date the revocation is received by the Company. I understand the revocation may be a basis for denying my insurance application, and that it does not alter the Company’s r ight to use the application for purposes of determining misrepresentation once coverage has been issued. I have received and read a copy of the Notice of Insurance Information Practices. Fraud For your protection, California law requires the following to appear on this form: The falsity of any statement in the application for any policy shall not bar the right to recovery under the policy unless such false statement was made with the actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer. PRE-EXISTING CONDITIONS LIMITATION – Applicable to Accident and Health Insurance Only – For Residents of NY With respect to group disability insurance, I understand that the policy/certificate may include a pre-existing condition provision that limits or excludes coverage for a period of time if I have a pre-existing condition as defined on the date my coverage becomes effective. I also understand that I may obtain additional information regarding this provision by referring to the group policy and/or certificate. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 (CA) Page 5 of 5 Certification I hereby represent that I have reviewed the above questions and that all statements and answers contained herein are full, complete, and true to the best of my knowledge and belief. For residents of Virginia only: I have read, or had read to me, the completed application, and I realize that any false statement or misrepresentation in the application may result in loss of coverage under the policy. This application will be made a part of the Policy. / / Employee Signature Date Signed Please mail the completed Employer Group Benefits Coverage Information page and Evidence of Insurability application to: The Hartford Group Medical Underwriting P.O. Box 2999 Hartford, CT 06104-2999 If you have any questions or concerns, please call The Hartford Customer Service Department toll-free at 1-800-331-7234, Monday through Friday, 8:00 a.m. to 6:00 p.m., Eastern Time, or email us at medical.uw@thehartford.com.