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
Enrollment Period
9/22/09
Spouse Supplemental Life Insurance
If you elect Supplemental Life Insurance for yourself, you may elect Spouse Supplemental Life Insurance in increments of $10,000. The
maximum amount you can purchase cannot be more than the lesser of $250,000 or 100% of your elected and approved Supplemental Life
Insurance. If you are currently participating in this coverage and currently have an amount more than or equal to $30,000 you may increase
your coverage by $10,000 without providing evidence of insurability. Additional coverage amounts will require evidence of insurability that is
satisfactory to The Hartford before the excess can become effective.
If you are newly eligible and electing for the first time or are currently enrolled with an amount less than $30,000 you may elect an amount up
to the guaranteed issue amount $30,000 without providing evidence of insurability. Additional coverage amounts will require evidence of
insurability that is satisfactory to The Hartford before the excess can become effective.
Costs are based on your Spouse’s age.
Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Rate $0.55 $0.55 $0.61 $0.67 $0.92 $1.39 $2.26 $3.91 $4.19 $7.33 $13.05 $20.77 $29.51 $46.42 $77.57
To calculate your Monthly cost, please use the following formula(s):
÷ $10,000 = x = $
Life Benefit Amount Rate Above My Monthly Cost*
I elect to purchase the total amount of $________________ in Life coverage for my Spouse.
SPOUSE:
First Name Last Name Gender Date of Birth Date of Marriage
Child(ren) Supplemental Life Insurance
If you purchase Supplemental Life Insurance for yourself, you may purchase Child(ren) Supplemental Life Insurance for your Dependent
Child(ren) between the ages of Live Birth and 19 years (26 years if a full time student) in increments of $1,000. The maximum amount you
can purchase is $25,000.
Please
your election.
I Elect Life
in the total
amount of
and My
Benefit
Will Be:
My total
Monthly
Cost for all
my
Covered
Child(ren)
Will Be:
I Elect Life in
the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life in
the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life
in the total
amount of
and My
Benefit Will
Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
I Elect Life in the
total amount of
and My Benefit
Will Be:
My total
Monthly
Cost for
all my
Covered
Child(ren)
Will Be:
$1,000 $0.19 $6,000 $1.15 $11,000 $2.11 $16,000 $3.07 $21,000 $4.03
$2,000 $0.38 $7,000 $1.34 $12,000 $2.30 $17,000 $3.26 $22,000 $4.22
$3,000 $0.58 $8,000 $1.54 $13,000 $2.50 $18,000 $3.46 $23,000 $4.42
$4,000 $0.77 $9,000 $1.73 $14,000 $2.69 $19,000 $3.65 $24,000 $4.61
$5,000 $0.96 $10,000 $1.92 $15,000 $2.88 $20,000 $3.84 $25,000 $4.80