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State Of Health (Lansing Community College)

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Employer Group Benefits Coverage Information
The Hartford
®
is The Hartford Financial Services Group, Inc. and its subsidiaries.
Page 1 of 6
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: 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 Email Address:
Benefits Contact Phone:
Section 2: Employee Details (to be completed by Employer)
PLEASE PRINT CLEARLY
Employee Name (First, MI, Last):
Date of Hire (mm/dd/yyyy):
Base Annual Earnings*:
Coverage Effective Date* (mm/dd/yyyy):
* As described in the contract with The Hartford
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
Current Life Coverage, including GI
Employee Basic Life
$
$
Employee Supplemental or Voluntary Life
$
$
Spouse Basic Life
$
$
Spouse Supplemental or Voluntary Life
$
$
Disability Insurance Coverage Requested
• Check Yes if employee is requesting Long Term Disability coverage that is subject to EOI
Long Term Disability
☐
Yes, EOI is required
Clear Form
LANSING COMMUNITY COLLEGE
877707
The Hartford
®
is The Hartford Financial Services Group, Inc. and its subsidiaries.
Form PA-9597 Page 2 of 6
EVIDENCE OF INSURABILITY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
One Hartford Plaza, Hartford, CT 06155
Applicant Information
First Name
Last Name
Social Security #
Gender
Height (ft./in.)
Weight (lbs.)*
Date of Birth
(mm/dd/yyyy)
Employee
Male
Female
Spouse
Male
Female
* If currently pregnant, please provide pre-pregnancy weight
Street Address Day Time Phone
Employee City Evening Phone
State, Zip Code Email Address
Street Address Day Time Phone
Spouse City Evening Phone
State, Zip Code Email 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.
Employee
Spouse
Within the past 5 years, have you been diagnosed with or treated by a licensed medical physician for Acquired Immune
Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) caused by the Human Immunodeficiency Virus (HIV)
infection or other sickness or condition derived from such infection?
Yes
No
Yes
No
Are you currently pregnant?
Yes
No
Yes
No
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?
Yes
No
Yes
No
Within the past 5 years, have you used any controlled substances, with the exception of those taken as prescribed by your
physician, been diagnosed or treated for drug or alcohol abuse (excluding support groups), or been convicted of operating
a motor vehicle while under the influence of drugs or alcohol?
Yes
No
Yes
No
The Hartford
®
is The Hartford Financial Services Group, Inc. and its subsidiaries.
Form PA-9597 Page 3 of 6
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 “Yes” if you only have High
Blood Pressure or a Heart Murmur)
Yes
No
Yes
No
Disease, injury or surgery of Joint, Ligaments,
Knee, Back, or Neck (including Arthritis)
Yes
No
Yes
No
Heart-Related Surgery or
Heart Attack
Yes
No
Yes
No
Muscular Dystrophy
Yes
No
Yes
No
High Blood Pressure
If you checked “Yes” to High Blood Pressure,
have you had a change in medication within
the last 6 months?
Yes
No
Yes
No
Yes
No
Yes
No
Hepatitis (Do not check “Yes” for Hepatitis A)
or Cirrhosis
Yes
No
Yes
No
Blocked Arteries (Arteriosclerosis,
Atherosclerosis, Aneurysm, or Deep Vein
Blood Clot)
Yes
No
Yes
No
Amyotrophic Lateral Sclerosis (ALS) or
Multiple Sclerosis (MS)
Yes
No
Yes
No
Stroke or transient ischemic attack (TIA)
Yes
No
Yes
No
Alzheimer’s or Parkinson’s Disease
Yes
No
Yes
No
Chronic Obstructive Pulmonary Disease
(COPD) or Emphysema
Yes
No
Yes
No
Paralysis
Yes
No
Yes
No
Diabetes
Yes
No
Yes
No
Major Organ Transplant
Yes
No
Yes
No
Depression
Yes
No
Yes
No
Chronic Fatigue Syndrome or Fibromyalgia
Yes
No
Yes
No
Sleep Apnea
Yes
No
Yes
No
Narcolepsy
Yes
No
Yes
No
Cancer (Do not check “Yes” for Basal Cell
Carcinoma only)
If “Yes”, Date of Diagnosis:
Yes
No
Yes
No
Ulcerative Colitis or Crohn’s Disease
Yes
No
Yes
No
Psychotic, Psychiatric, Personality, or Bi-Polar
Disorder
Yes
No
Yes
No
Kidney Failure or Dialysis
Yes
No
Yes
No
Notice
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 4 of 6
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 e-mail, 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.
Yes, you may leave a message as indicated above. No, 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 Notice of Insurance Information Practices.
The Hartford
®
is The Hartford Financial Services Group, Inc. and its subsidiaries.
Form PA-9597 Page 5 of 6
Fraud
For any Applicants that do not reside in the following states: Alabama, Colorado, District of Columbia, Florida, Kentucky, Maine,
Maryland, New Jersey, Oregon, Pennsylvania, Puerto Rico, Tennessee 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 Alabama: 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 is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
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 District of Columbia:
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 is guilty of a crime and may be subject to fines and confinement in prison.
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 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 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 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.
PRE-EXISTING CONDITIONS LIMITATION – Applicable to Accident and Health Insurance Only – For Residents of NY
With respect to group disability insurance, I understand that the policy/certificate may include a pre-existing condition provision that limits or excludes
coverage for a period of time if I have a pre-existing condition as defined on the date my coverage becomes effective. I also understand that I may
obtain additional information regarding this provision by referring to the group policy and/or certificate.
The Hartford
®
is The Hartford Financial Services Group, Inc. and its subsidiaries.
Form PA-9597 Page 6 of 6
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 06104-2999
If you have any questions or concerns, please call The Hartford Customer Service Department toll-free at 1-800-331-7234, Monday through Friday,
8:00 a.m. to 6:00 p.m., Eastern Time, or email us at medical.uw@thehartford.com
.
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State Of Health (Lansing Community College)

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Completed 23 July 2020

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