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Enrollment - enrollment_form_pa_9604

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The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.
Form PA-9604 Page 1 of 3
Version 2.2015
ENROLLMENT FORM
EMPLOYER
INFORMATION
EMPLOYER’S FULL LEGAL NAME
GROUP POLICY#
ENROLLMENT
INFORMATION
Please check one of the following:
INITIAL ENROLLMENT EFFECTIVE DATE:
CHANGE TO EXISTING ENROLLMENT EFFECTIVE DATE:
FAMILY STATUS CHANGE (TYPE): EFFECTIVE DATE:
EMPLOYEE
INFORMATION
EMPLOYEE NAME
DATE OF BIRTH
EMPLOYEE ID/SSN
DATE OF HIRE
ADDRESS
CITY
STATE
ZIP CODE
GENDER
M F
SPECIALTY/OCCUPATION
EARNINGS (AS DEFINED BY THE POLICY)
$
HR MO YR
# HOURS WORKED
PER WEEK
LOCATION
DEPENDENT
INFORMATION
SPOUSE’S NAME GENDER
M F
DATE OF
BIRTH
DATE OF
MARRIAGE
CHILD’S NAME GENDER M F DATE OF BIRTH
CHILD’S NAME GENDER M F DATE OF BIRTH
CHILD’S NAME GENDER M F DATE OF BIRTH
APPLICABLE
BENEFIT
ELECTIONS
Please make your benefit elections by checking the appropriate box. Contact your employer for plan details.
SHORT TERM DISABILITY
YES
NO
COST:
For DISABILITYFLEX
SM
choose:
WEEKLY BENEFIT CHOICE
$
BENEFIT DURATION
BENEFIT COMMENCEMENT PERIOD
LONG TERM DISABILITY YES NO
COST
:
CRITICAL ILLNESS EMPLOYEE
$
EMPLOYEE
AND CHILD(REN)
$
NO
TOBACCO USER YES NO
EMPLOYEE
AND SPOUSE
$
EMPLOYEE
AND FAMILY
$
COST
:
BASIC LIFE AND AD&D*
EMPLOYEE YES $ NO
COST
:
SPOUSE YES $ NO
COST
:
CHILD YES $ NO
COST
:
*If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.
SUPPLEMENTAL LIFE AND AD&D*
EMPLOYEE YES $ NO
COST
:
SPOUSE YES $ NO
COST
:
CHILD YES $ NO
COST
:
*If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.
SUPPLEMENTAL AD&D
EMPLOYEE YES $ NO
COST
:
SPOUSE YES $ NO
COST
:
CHILD YES $ NO
COST
:
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
One Hartford Plaza, Hartford, CT 06155
(A stock insurance company)
Clear Form
Lansing Community College
877707
■
■
■
■
■
■
■
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.
Page 2 of 3
Version 2.2015
APPLICABLE
BENEFIT
ELECTIONS
CONTINUED
ACCIDENT
EMPLOYEE EMPLOYEE AND SPOUSE NO
PLAN OPTION:
EMPLOYEE AND CHILD(REN)
EMPLOYEE AND FAMILY
COST
:
BENEFICIARY
INFORMATION
You 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.
Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than
one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the
information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their
stated relationship. If you need assistance, contact your benefits administrator or your own legal advisor.
This beneficiary designation will be for ALL group life or accidental death insurance coverage issued by The Hartford for you. A
primary beneficiary is the beneficiary or beneficiaries that you name to receive the benefits if they are living at the time of your death.
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
NAME
SOCIAL SECURITY #
DATE OF BIRTH
RELATIONSHIP
PERCENTAGE
ADDRESS
PHONE NUMBER
NAME
SOCIAL SECURITY #
DATE OF BIRTH
RELATIONSHIP
PERCENTAGE
ADDRESS
PHONE NUMBER
CONTINGENT BENEFICIARY
NAME
SOCIAL SECURITY #
DATE OF BIRTH
RELATIONSHIP
PERCENTAGE
ADDRESS
PHONE NUMBER
NAME
SOCIAL SECURITY #
DATE OF BIRTH
RELATIONSHIP
PERCENTAGE
ADDRESS
PHONE NUMBER
The beneficiary for insurance on the lives of your dependents will automatically be you, if surviving. Otherwise, the beneficiary will
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 – Alaska, Arizona, California, Idaho,
Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, and 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. Certain tribal jurisdictions may also require spousal consent. Please see your Benefits
Administrator for details.
This will represent 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 or accidental death 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 an
y
prior
spousal consent or waiver under this plan.
SIGNATURE OF EMPLOYEE’S SPOUSE DATE
■
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.
Page 3 of 3
Version 2.2015
CONFIRMATION I acknowledge that I have been given the opportunity to enroll in the insurance coverage offered by my employer. I understand and
agree that if I decline coverage now, but later decide to enroll, I may be required to provide evidence of insurability that is satisfactory
to The Hartford and be approved for such coverage before it becomes effective. I understand m
y
request for covera
g
e ma
y
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
conditions 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. In the event of any difference between the
enrollment form and the insurance policy, I agree to be bound by the insurance policy.
If 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. If I have disability income coverage with The Hartford, I understand and agree that the maximum duration
of benefits payable will be limited to a specified period which may start at a specified age and that a claim for benefits may not be
approved for a pre-existing condition.
If I have critical illness insurance coverage with The Hartford, I understand and agree that my
critical illness insurance benefit is terminated at a specified age stated in the policy and that a claim for benefits may not be approved
for a pre-existing condition.
I authorize payroll deductions from my wages to cover my cost of coverage when applicable.
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 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 Notice(s)
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.
For Residents of Louisiana and Maryland:
Any person who knowingly (knowingly or willfully in Maryland) presents a false or fraudulent claim for payment of a loss or benefit 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 (Not applicable to Life Insurance):
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 Virginia:
It 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
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Completed 7 December 2019

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