Information About You Employee ID (if not available, then Social Security Number):

Transcription

1 S VL1_Value Supplemental Life and AD&D Insurance T his this text box here. A post process uses the text above to do a "Find/Replace" of variable text and the header. Template: Life_BHS Supplemental Life and AD&D Insurance Benefit Highlights Florida Department of Revenue What is s upplemental life a nd AD&D insurance? S upplemental life and AD&D insurance is coverage that you pay for. Supplemental life and AD&D insurance p ays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your supplemental life and AD&D insurance. Once a g roup policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. Am I eligible? When can I enroll? When is it effective? How much s upplemental l ife and AD&D insurance c an I purchase? AD&D Coverage Y ou are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis. Y ou can enroll during your scheduled enrollment period, within 31 days of the date you h ave a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy. C overage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect. You can purchase s upplemental life and AD&D insurance in increments of $ 10,000. The maximum amount you can purchase cannot be more than 5 t imes your annual earnings o r $ 300,000. Annual e arnings are a s defined in The Hartford s contract with your employer. A D&D provides benefits due to certain injuries or death from an accident. The covered injuries or death can occur up to 365 days after that accident. The insurance pays: 100% of the amount of coverage you purchase in the event of accidental loss of life, t wo limbs, the sight of both eyes, one limb and the sight of one eye, or speech and hearing in both ears or quadriplegia. 75% for paraplegia or triplegia (paralysis of three limbs). O ne-half (50%) for accidental loss of one limb, sight of one eye, or speech or hearing in both ears or hemiplegia. O ne-quarter (25%) for accidental loss of thumb and index finger of the same hand or uniplegia. Y our total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase. T he Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford L ife Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. F lorida Department of Revenue Life BHS C reation Date: 3/24/2015 Page 1 of 4 Version 11/12

2 I already have s upplemental life and A D&D insurance c overage; do I have to do anything? A re A m I guaranteed coverage? What is a beneficiary? there other limitations to enrollment? If you take no action, your coverage and coverage for your eligible dependents w ill automatically continue with The Hartford subject to the terms of the contract. I f you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $ 80,000, you will need to provide evidence of insurability that is satisfactory to The H artford before the excess can become effective. If you were previously eligible and are e lecting coverage for the first time or electing to increase your current coverage, you will n eed to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. Y our beneficiary is the person (or persons) or legal entity (entities) who receives a benefit p ayment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding. I f you do not enroll within 31 days of your first day of eligibility, you will be considered a l ate entrant. Typically, late entrants may need to show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required. S pouse supplemental life i nsurance If you elect supplemental life and AD&D insurance for yourself, yo u may choose to purchase s pouse supplemental life insurance in increments of $ 5,000, to a maximum of $ 150,000. C overage cannot exceed 50% of the amount of your employee v oluntary/supplemental life i nsurance coverage. You may not elect coverage for your spouse if they are in active full- time military service or is already covered as an employee under this policy. I f your spouse is confined in a hospital or elsewhere because of disability on the date his o r her insurance would normally have become effective, coverage (or an increase in c overage) will be deferred until that dependent is no longer confined and has performed a ll the normal activities of a healthy person of the same age for at least 15 consecutive days. I f you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $ 30,000, your spouse will need to provide evidence of insurability that is satisfactory to T he Hartford before the excess can become effective. If you were previously eligible and a re electing coverage for the first time or electing to increase your spouse's current c overage, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. F lorida Department of Revenue Life BHS C reation Date: 3/24/2015 Page 2 of 4 Version 11/12

3 C hild(ren) supplemental life insurance If you elect supplemental life and AD&D insurance for yourself, yo u may choose to purchase c hild(ren) supplemental life insurance c overage in increments of $ 2,000, to a maximum of $ 10,000 f or each child no medical information is required. I f your dependent child(ren) is confined in a hospital or elsewhere because of d isability on the date his or her insurance would normally have become effective, c overage (or an increase in coverage) will be deferred until that dependent is no l onger confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. Child(ren) must be unmarried and their age must be a t least 15 days but not yet 19 y ears ( or 25 y ears if a full time student) t o be covered. Unmarried child(ren) over age 19 m ay be covered if they are disabled and primarily dependent upon the employee for financial support. Child(ren) a t least 15 days but not yet age 6 months a re limited to a reduced benefit of $ 100. D oes my coverage reduce as I get older? C an I keep my life c overage if I leave my e mployer? W hat is the living benefits option? D o I still pay my life i nsurance premiums if I become disabled? 50% at age 70. All coverage cancels at retirement., subject to the contract, you have the option of: Converting your group life coverage to your own individual policy (policies). If you are diagnosed as terminally ill with a 12 m onth life expectancy, you may be eligible t o receive payment of a portion of your life insurance. The remaining amount of your life insurance would be paid to your beneficiary when you die. If you become totally disabled before age 60 and your disability lasts for at least 9 m onths, your life insurance premium may be waived. T he premium for your dependent s coverage w ill also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates. Important Details As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions: the amount of your coverage may be reduced when you reach certain ages. death by suicide (two years). AD&D insurance does not cover losses caused by or contributed by: sickness; disease; or any treatment for either; a ny infection, except certain ones caused by an accidental cut or wound; i ntentionally self-inflicted injury, suicide or suicide attempt; war or act of war, whether declared or not; i njury sustained while in the armed forces of any country or international authority; t aking prescription or illegal drugs unless prescribed for or administered by a licensed physician; i njury sustained while committing or attempting to commit a felony; the injured person s intoxication. O ther exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. F lorida Department of Revenue Life BHS C reation Date: 3/24/2015 Page 3 of 4 Version 11/12

4 T his benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is n ot a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder ( your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance c overage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply. F lorida Department of Revenue Life BHS C reation Date: 3/24/2015 Page 4 of 4 Version 11/12

5 HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY One Hartford Plaza, Hartford, CT (A stock insurance company) Florida Department of Revenue Benefits Enrollment Form, # Instructions Please enter all required information clearly so that there will be no question as to your meaning. Step 1: Please enter and/or check your coverage elections. Make sure the coverage amount that you elect includes your existing coverage amount. You may only elect and will be covered for levels of coverage included in your employer s contract. Step 2: Please sign, date and return this form to CAPITAL INSURANCE AGENCY, INC., P. O. BOX 15949, TALLAHASSEE, FLORIDA Do not mail this form back to The Hartford s address indicated at the top of this form. Information About You Employee Name: Employee ID (if not available, then Social Security Number): Date of Birth: Date of Hire: Dependent Information If more than 4 child(ren), attach additional sheet. Spouse Name: Gender: Spouse Date of Birth: Date of Marriage: M F Child Name: Gender: Date of Birth: Child Name: Gender: Date of Birth: M F M F M F M F The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9604 Florida Department of Revenue Generic Creation Date: 3/25/2015 Page 1 of 4

6 Name: Supplemental Life and AD&D Insurance Y our cost may change when you move into a new age category. Age Rate Under To calculate your m onthly cost, please use the following formula(s): $1,000 = x = $ Life a nd AD& D Rate M onthly Cost Benefit Amount I elect to p urchase $ of life a nd AD&D coverage. I d ecline t o purchase life a nd AD&D coverage. I elect to c ontinue m y current life a nd AD&D coverage. S pouse Supplemental Life Insurance C osts are based on your spouse s age. Your cost may change when y our spouse moves into a new age category. Age Rate Under To calculate your m onthly cost, please use the following formula(s): $1,000 = x = $ L ife B enefit Amount Rate M onthly Cost I elect to p urchase $ of life coverage. I d ecline t o purchase life coverage. I elect to c ontinue m y current life coverage. Child(ren) Supplemental Life Insurance To calculate your m onthly cost, please use the following formula(s): Life B enefit Amount $1,000 = x $ Rate = $ M onthly Cost I elect to p urchase $ o f life coverage. I d ecline t o purchase life coverage. I elect to c ontinue m y current life coverage. Beneficiary Designation Y ou must select your beneficiary the person (or more than one person) or legal entity (or more than one entity) who receives a benefit payment if you die while covered by the plans. Please make sure that you also name a contingent beneficiary who would receive your benefit if your primary beneficiary dies first. P lease make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more t han one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all o f the information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, t Related as their stated relationship. If you need assistance, contact your benefits administrator or your own legal advisor. T his beneficiary designation will be for ALL group life or accidental death insurance coverage issued by The Hartford for you. A The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. F lorida Department of Revenue Generic C reation Date: 3/25/2015 Page 2 of 4

7 Name: p rimary beneficiary is the beneficiary or beneficiaries that you name to receive the benefits if they are living at the time of your d eath. The primary beneficiaries are the first in line to receive death benefits. Contingent beneficiaries, or secondary beneficiaries, are those named to receive the insurance proceeds if no primary beneficiary is alive at the time you die. PRIMARY BENEFICIARY P rimary Beneficiary Name: S ocial Security #: D ate of Birth: R elationship: Percentage: A ddress: Phone Number: P rimary Beneficiary Name: S ocial Security #: D ate of Birth: R elationship: Percentage: A ddress: Phone Number: CONTINGENT BENEFICIARY C ontingent Beneficiary Name: S ocial Security #: D ate of Birth: R elationship: Percentage: A ddress: Phone Number: C ontingent Beneficiary Name: S ocial Security #: D ate of Birth: R elationship: Percentage: A ddress: Phone Number: T he beneficiary for insurance on the lives of your dependents will automatically be you, if surviving. Otherwise, the beneficiary w ill be subject to policy provisions. A beneficiary for employee life or accidental death insurance may be changed upon written request. Consent For Community Property States Only: If you live in a community property state A laska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and Wisconsin you may complete the Spousal C onsent section, which allows your spouse to waive his or her rights to any community property interest in the benefit. Disclaimer: S pousal consent does not apply to ERISA plans. Certain tribal jurisdictions may also require spousal consent. Please see your Benefits Administrator for details. T his will represent that, as spouse of the employee named above, I hereby consent to my spouse designating the person(s) l isted above as beneficiaries of group life or accidental death insurance under the above policy and waive any rights I may h ave to the proceeds of such insurance under applicable community property laws. I understand that this consent and waiver supersede any prior spousal consent or waiver under this plan. Signature of Employee s Spouse: Date: Confirmation I acknowledge that I have been given the opportunity to enroll in the insurance coverage offered by my employer. I understand a nd agree that if I decline coverage now, but later decide to enroll, I may be required to provide evidence of insurability that is s atisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be denied by The Hartford. I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and c onditions of the insurance policy. I understand and agree that only the insurance policy issued to my employer can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance coverage. I n the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy. I f I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit(s) reduce at a specified age(s) stated in the policy. I authorize payroll deductions from my wages to cover my cost of coverage when applicable. I understand rates and benefits The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. F lorida Department of Revenue Generic C reation Date: 3/25/2015 Page 3 of 4

8 Name: may be changed by the insurer. I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as i ssued to my employer. I acknowledge and agree that if group participation requirements are required by The Hartford or by law and are not met, the policy will not be implemented and the coverage I have elected will not be in force. Fraud tice(s) For Residents of Louisiana and Maryland: A ny person who knowingly (knowingly or willfully in Maryland) presents a false or fraudulent claim for payment of a loss or b enefit or knowingly (knowingly or willfully in Maryland) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For Residents of New York (t applicable to Life Insurance): A ny person who knowingly and with intent to defraud any insurance company or other person files an application for i nsurance or statement of claim containing any materially false information, or conceals for the purpose of m isleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, a nd 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. For Residents of Virginia: I t is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Signed Date The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. F lorida Department of Revenue Generic C reation Date: 3/25/2015 Page 4 of 4

9 Employer Group Benefits Coverage Information 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. Employees: Please completely fill out the Applicant Information section on the 2 nd page even if you are not applying for coverage. Section 1: Employer Details (to be completed by Employer) PLEASE PRINT CLEARLY Employer Name: Florida Department of Revenue 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 Address: Section 2: Employee Details (to be completed by Employer) Employee Name (First, MI, Last): Base Annual Earnings*: * As described in the contract with The Hartford Benefits Contact Phone: Date of Hire (mm/dd/yyyy): Coverage Effective Date* (mm/dd/yyyy): PLEASE PRINT CLEARLY 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 Employee Basic Life Employee Supplemental or Voluntary Life Spouse Basic Life Spouse Supplemental or Voluntary Life Current Life Coverage, including GI $ $ $ $ $ $ $ $ Life Coverage Subject to EOI The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. Page 1 of 5 FL

10 Employee: First Name Middle Initial Last Name EVIDENCE OF INSURABILITY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY One Hartford Plaza, Hartford, CT Applicant Information Employee First Name Last Name Social Security # Gender Height (ft./in.) Weight (lbs.)* Male Female Date of Birth (mm/dd/yyyy) Spouse * If currently pregnant, please provide pre-pregnancy weight Male Female Street Address Day Time Phone Employee City State, Zip Code Evening Phone Address Spouse Street Address City State, Zip Code Day Time Phone Evening Phone Address Spouse s Address is the same as the Employee s Medical Information Each Applicant must answer each of the following questions to the best of their knowledge and belief. Within the past 5 years, have you 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? Have you been diagnosed or are you being treated by a licensed member of the medical profession for pregnancy? 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? Within the past 5 years, have you used any drugs or narcotics, with the exception of those taken as prescribed by your physician? Within the past 5 years, have you been diagnosed or treated by a licensed medical professional for drug or alcohol abuse (excluding support groups)? Within the past 5 years, have you been convicted of operating a motor vehicle while under the influence of drugs or alcohol? Employee Spouse The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 Page 2 of 5

11 Employee: First Name Middle Initial Last Name Medical Information (continued) Within the past 5 years, have you been diagnosed with or treated by a licensed member of the medical profession for: Employee Spouse Employee Spouse Heart Disease (Do not check if you only have High Blood Pressure or a Heart Murmur) Disease, injury or surgery of Joint, Ligaments, Knee, Back, or Neck (including Arthritis) Heart-Related Surgery or Heart Attack Muscular Dystrophy High Blood Pressure If you checked to High Blood Pressure, have you had a change in medication within the last 6 months? Hepatitis (Do not check for Hepatitis A) or Cirrhosis Blocked Arteries (Arteriosclerosis, Atherosclerosis, Aneurysm, or Deep Vein Blood Clot) Amyotrophic Lateral Sclerosis (ALS) or Multiple Sclerosis (MS) Stroke or transient ischemic attack (TIA) Alzheimer s or Parkinson s Disease Chronic Obstructive Pulmonary Disease (COPD) or Emphysema Paralysis Diabetes Major Organ Transplant Depression Chronic Fatigue Syndrome or Fibromyalgia Sleep Apnea Narcolepsy Cancer (Do not check for Basal Cell Carcinoma only) If, Date of Diagnosis: Ulcerative Colitis or Crohn s Disease Psychotic, Psychiatric, Personality, or Bi- Polar Disorder Kidney Failure or Dialysis tice 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 Page 3 of 5

12 Employee: First Name Middle Initial Last Name 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 , 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., you may leave a message as indicated above., 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 during 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 right to use the application for purposes of determining misrepresentation once coverage has been issued. I have received and read a copy of the tice of Insurance Information Practices. Fraud For any Applicants that do not reside in the following states: Colorado, California, Florida, Kentucky, Maine, Maryland, New Jersey, New York, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: 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 may be guilty of a crime and may be subject to fines and confinement in prison. For residents of California: 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 actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer. For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 Page 4 of 5

13 Employee: First Name Middle Initial Last Name For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim or an application for insurance 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. For residents of Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits. For residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. For residents of New York (Applicable to Accident and Health Insurance Only): 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. For residents of Oregon: 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 that the insurer relied upon is subject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available. For residents of Pennsylvania: 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 hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. For residents of Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. 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 Spouse 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 If you have any questions or concerns, please call The Hartford Customer Service Department toll-free at , Monday through Friday, 8:00 a.m. to 6:00 p.m., Eastern Time, or us at medical.uw@thehartford.com. The Hartford is The Hartford Financial Services Group, Inc. and its subsidiaries. Form PA-9597 Page 5 of 5