Name: _______________________________________________________________________________
Underwritten by Hartford Life And Accident Insurance Company. 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 Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
North American Division of Seventh-day Adventists
9/22/09
The beneficiary for insurance on the lives of your spouse and children will automatically be you, if surviving. Otherwise, the beneficiary will
be the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon
written request.
Spousal Consent For Community Property States Only: If you live in a community property state – Arizona, California, Idaho, Louisiana,
Nevada, New Mexico, Texas, Washington, or Wisconsin – you may complete the Spousal Consent section, which allows your spouse to
waive his or her rights to any community property interest in the benefit. Disclaimer: Spousal consent does not apply to ERISA plans.
This will certify that, as spouse of the Employee named above, I hereby consent to my spouse designating the person(s) listed above as
beneficiaries of group life insurance under the above policy and waive any rights I may have 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 Accident insurance coverage described in the Benefit Highlight Sheets
and offered through North American Division of Seventh-day Adventists.
I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of
the insurance policy. I understand and agree that only the insurance policy issued to the policyholder (your employer) can fully describe the
provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the enrollment
form and the insurance policy, I agree to be bound by the insurance policy.
I authorize my employer to make the appropriate payroll deductions from my earnings.
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 issued to my
employer. I acknowledge and agree that if group participation requirements are not met, this policy will not be implemented and the
coverage I have elected will not be in force.
Signed Date
