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imfmoore_mda-ca-groupdisabilityincome Office of the Administrator P.O. BOX 14464 Des Moines, IA 50306-9468 Dear, Thank you for inquiring about the Minnesota Dental Association Group Insurance Program. Enclosed you'll find the information you requested for the following plan: Group Disability Income Plan. Before you take a look at the information I've enclosed, let me mention some of the important benefits you receive with all our insurance plans. l These are "group" plans, negotiated especially for MDA Members. Rates, although not guaranteed, can only be changed on a group basis. l Each plan is backed by a 30-day Free Look. After you receive your Certificate of Insurance, you have a full 30 days to review your new coverage. If you decide that it's not exactly what you want and need, simply return it. Every dollar you've paid will be refunded, and your coverage will be invalidated, no questions asked provided of course, you have not submitted any claims. Please read the enclosed brochure for more information, including eligibility, renewability, costs, exclusions, limitations and terms of coverage on this plan. Once you determine the type and amount of personal insurance protection you need, simply complete and return the application in the postage-paid envelope provided for approval. If you have questions along the way, just pick up the phone and call us. Our toll-free number is: 1-866-810-9384. Whatever your personal situation, I hope you'll take a few minutes today to candidly assess your family's insurance needs and apply to bring your coverage up-to-date through this exclusive member program. Please return your application today! Yours truly, Terence B. Bernier Managing Director Marsh U.S. Consumer a Service of Seabury & Smith, Inc. #2177453 P.S. Each insurance plan is offered through a well respected, highly rated insurance company, and every plan carries a 30-day Free Look! Marsh U.S. Consumer a Service of Seabury & Smith, Inc. P.O. BOX 14464 l Des Moines, IA 50306 1-866-810-9384 l mda@marshpm.com l www.mndentalsolutions.com œseabury & Smith, Inc. March 2011 AGP-5541 0000047-0000001-0000034

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For Members of the Minnesota Dental Association DISABILITY INSURANCE APPLICATION HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 TO APPLY: 1. Complete and sign the application 2. Send no money with your application. You will be billed upon approval. 3. Use the postage paid envelope provided to return to: MDA GROUP INSURANCE PROGRAM P.O. Box 14464 Des Moines, IA 50306 E-Mail: mda@marshpm.com 90935 055670010199 Minnesota Dental Association Annual Salary: $ The Hartford is 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. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 1 0000049-0000003-0000034

Spouse/Domestic Partner's Name: (First, Middle Initial, Last), if applying Spouse/Domestic Partner's Occupation: Annual Salary: $ Section 4 COVERAGE REQUESTED: Member Coverage: GNew Coverage: Monthly Benefit Amount: $ GChange in Coverage: Increase my Monthly Benefit Amount to: $ GChange in Waiting Period: Waiting Period: G90 days G180 days Spouse/Domestic Partner Coverage: GNew Coverage: Monthly Benefit Amount: $ GChange in Coverage: Increase my Monthly Benefit Amount to: $ GChange in Waiting Period: Waiting Period: G90 days G180 days Has anyone proposed for coverage been actively engaged in the full-time duties of his or her occupation (at least 25 hours per week) immediately before the date of this application? You: GYes GNo Spouse/Domestic Partner: GYes GNo Is the Monthly Benefit Amount herein applied for equal to or less than 60% of your Pre-Disability Earnings minus any Other Income Benefits? You: GYes GNo Spouse/Domestic Partner: GYes GNo The Hartford is 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. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 2 *00240002000* 0000050-0000004-0000034

Member Spouse/ Domestic Partner Section 8 AUTHORIZATION I hereby certify that I have read or have had read to me all statements and answers in this application, and in any other application or medical form required by Hartford Life and Accident Insurance Company, and that they are full, complete, and true to the best of my knowledge and belief. I understand that any material misrepresentations in this application could cause a claim to be denied under any insurance issued based on this application. I understand that any intent to defraud or knowingly facilitate a fraud against the Company, by submitting an application or filing a claim containing a false or deceptive statement is insurance fraud. I also agree that a copy of this application shall be attached to and form a part of any certificate issued. I also understand that the Company may request whatever additional evidence of insurability it needs. Subject to the deferred effective date provision, I understand that coverage will not become effective until the Company grants its underwriting approval. I do not receive temporary or conditional insurance coverage just because I submit an application and pay the first premium. The Hartford is 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. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 3 0000051-0000005-0000034

I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or reinsurer; Medical Information Bureau, Inc.; or employer; to give Hartford Life and Accident Insurance Company or its legal representative information about my/our physical or mental health, (including history, condition, diagnosis and treatment), drug or alcohol use history, other insurance coverage or employment status except drug and alcohol treatment information. Hartford Life and Accident Insurance Company will use the information to decide if and to what extent we are eligible for insurance coverage or benefits under the policy. This information will be treated as confidential. I understand the Medical Information Bureau, Inc. will release records or information only to Hartford Life and Accident Insurance Company. I authorize Hartford Life and Accident Insurance Company to give information about me/us 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 the authorization. This authorization expires two (2) years 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. I certify that I have received the Notice of Insurance Information Practices. I agree that this document and all its contents shall form a part of my enrollment request for group benefits. PRE-EXISTING CONDITIONS LIMITATION: I understand that any injury or sickness, diagnosed or undiagnosed, for which I have received medical advice or treatment in the 12 month period prior to my effective date of coverage will not be covered until I have gone 12 months ending on or after my effective date of coverage without medical advice or treatment for that condition, or until 1 year after my effective date of coverage, whichever comes first, provided that the condition is not specifically excluded or limited by the policy or by a Health Waiver attached to my certificate. Applications to increase coverage will be subject to a new pre-existing conditions limitation. I further understand that any condition excluded or limited by the Policy or by a Health Waiver attached to my certificate will not be covered under this Policy at any time. Notice: I understand that California law prohibits an HIV test from being required or used by Health Insurance Companies as a condition of obtaining health insurance coverage. Section 9 I wish to pay my premiums: G Automatic Monthly Check Withdrawal G Semi-Annual Direct Bill (If you select Automatic Check Withdrawal, please complete the Automatic Monthly Check Withdrawal Request.) Section 10 Member's signature (Sign name in full) Required Date Required Spouse/Domestic Partner's signature (if applying) Required Date Required Send this completed form to: ADMINISTRATOR MDA GROUP INSURANCE PROGRAM P.O. Box 14464 Des Moines, IA 50306 1-866-810-9384 mda@marshpm.com The Hartford is 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. Form PA-9357 (HLA) (CA) IDI648CAE-AGP5541E 4 *00250003000* 0000052-0000006-0000034

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Marsh U.S. Consumer, a Service of Seabury & Smith, Inc. P.O. Box 14464 Des Moines, IA 50306 Administered by: P.O. BOX 14464 Des Moines, IA 50306-9468 Call: 1-866-810-9384 Web: www.mndentalsolutions.com AR Ins. Lic. #245544 CA Ins. Lic. #0633005 d/b/a in CA Seabury & Smith Insurance Program Management Underwritten by: Hartford Life and Accident Insurance Company Simsbury, CT 06089 (Next page, please) 0000059-0000013-0000034

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