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Fill in Your Evidence Of Insurance Template

The Evidence of Insurance form serves as a crucial document for individuals seeking life insurance coverage through their employer. This form must be completed in full and submitted to The Hartford within 30 days of signing to ensure timely processing of the insurance request. Providing accurate and complete information is essential, as any omissions can lead to delays in obtaining coverage.

Table of Contents

The Evidence of Insurance form plays a crucial role in ensuring that employees receive the insurance coverage they need through their employer. This form must be completed thoroughly and submitted to The Hartford within 30 days of the signature date to avoid delays in processing. Employers are responsible for filling out the initial sections, which include important details such as the employer's name, policy number, and contact information. Following this, employee-specific information is required, including the employee's name, date of hire, and annual earnings. The form also outlines the types of life insurance coverage requested, including basic and supplemental options for both employees and their dependents. Each applicant must answer a series of medical questions to assess their eligibility for coverage. This section is vital, as it helps the insurer determine the risk associated with providing coverage. The form concludes with an authorization section, allowing The Hartford to collect necessary medical information to evaluate the application. Completing this form accurately is essential for a smooth insurance process, ensuring that employees can access the benefits they deserve.

Sample - Evidence Of Insurance Form

Clear Form

Employer Group Benefits Coverage Information

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.

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,		Life Coverage Subject to
	including GI		EOI

Employee Basic Life	$		$

Employee Supplemental or Voluntary Life	$		$
Employee Supplemental or Voluntary Life

Spouse Basic Life	$		$
Spouse Basic Life

Spouse Supplemental or Voluntary Life	$		$
Spouse Supplemental or Voluntary Life

Child Supplemental or Voluntary Life
 Check Yes if employee is requesting Child Life coverage that is subject to EOI		☐ Yes, EOI is required
 Indicate the number of children applying: __________

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.

Page 1 of 5

EVIDENCE OF INSURABILITY

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

One Hartford Plaza, Hartford, CT 06155

Applicant Information

●If there are more than three Applicants, please provide the information on a separate sheet of paper.

Abbreviations: Employee = EE Spouse = SP Child = CH

First Name	Last Name	Social Security						Height	Weight	Date of Birth
		Number	EE	SP	CH		Gender	(ft./in.)	(lbs.)	(mm/dd/yyyy)
									If currently
									pregnant,
									pregnant,
				(check one)					pre-
				(check one)					pregnancy
									pregnancy
									weight
							Male
							Female

							Male
							Female

							Male
							Female

EE Address:					Day Time Phone:

						Evening Phone:

						Email Address:

SP Address:					Day Time Phone:

same as EE						Evening Phone:

						Email Address:
						Email Address:

CH Address:					Day Time Phone:

						Evening Phone:
same as EE
same as EE						Email Address:
						Email Address:

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.

Form PA-9597 (CA)

Page 2 of 5

Medical Information

Each Applicant must answer each of the following questions to the best of their knowledge and
belief. A Legal Guardian is required to answer each of the questions for minor children. If you have					EE	SP	CH
more than 1 child, specify which child(ren) the answer applies to on a separate sheet of paper.					EE	SP	CH


Within the past 5 years, have you been diagnosed with or treated by a licensed medical physician for					Yes	Yes	Yes
Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?					Yes	Yes	Yes
					No	No	No

Are you currently pregnant?					Yes	Yes	Yes
					Yes	Yes	Yes
					No	No	No

Within the past 5 years, with the exception of a past pregnancy, have you lost time from work for more than					Yes	Yes	Yes
10 consecutive work days due to a disability, injury, or sickness?					Yes	Yes	Yes
					No	No	No
					No	No	No

Within the past 5 years, have you used any controlled substances, with the exception of those taken as					Yes	Yes	Yes
prescribed by your physician, been diagnosed or treated for drug or alcohol abuse (excluding support					Yes	Yes	Yes
					No	No	No
groups), or been convicted of operating a motor vehicle while under the influence of drugs or alcohol?					No	No	No


Within the past 5 years, have you been diagnosed with or treated by a licensed member of the medical profession for:

	EE	SP	CH		EE	SP	CH
Heart Disease	Yes	Yes	Yes	Disease, injury or surgery of	Yes	Yes	Yes
(Do not check “Yes” if you only have High	Yes	Yes	Yes	Joint, Ligaments, Knee, Back,	Yes	Yes	Yes
(Do not check “Yes” if you only have High	No	No	No	Joint, Ligaments, Knee, Back,	No	No	No
Blood Pressure or a Heart Murmur)	No	No	No	or Neck (including Arthritis)	No	No	No
Blood Pressure or a Heart Murmur)				or Neck (including Arthritis)

Heart-Related Surgery or	Yes	Yes	Yes	Muscular Dystrophy	Yes	Yes	Yes
Heart Attack	No	No	No	Muscular Dystrophy	No	No	No
Heart Attack	No	No	No		No	No	No

High Blood Pressure	Yes	Yes	Yes
	No	No	No	Hepatitis (Do not check “Yes”	Yes	Yes	Yes
If you checked “Yes” to High Blood				Hepatitis (Do not check “Yes”	Yes	Yes	Yes
If you checked “Yes” to High Blood				for Hepatitis A) or Cirrhosis	No	No	No
Pressure, have you had a change in	Yes	Yes	Yes	for Hepatitis A) or Cirrhosis	No	No	No
Pressure, have you had a change in	Yes	Yes	Yes
medication within the last 6 months?	No	No	No

Blocked Arteries (Arteriosclerosis,	Yes	Yes	Yes	Amyotrophic Lateral Sclerosis	Yes	Yes	Yes
Atherosclerosis, Aneurysm, or Deep Vein	Yes	Yes	Yes	(ALS) or Multiple Sclerosis	Yes	Yes	Yes
Atherosclerosis, Aneurysm, or Deep Vein	No	No	No	(ALS) or Multiple Sclerosis	No	No	No
Blood Clot)	No	No	No	(MS)	No	No	No
Blood Clot)				(MS)

Stroke or transient ischemic attack (TIA)	Yes	Yes	Yes	Alzheimer’s or Parkinson’s	Yes	Yes	Yes
Stroke or transient ischemic attack (TIA)	No	No	No	Disease	No	No	No
	No	No	No	Disease	No	No	No

Chronic Obstructive Pulmonary Disease	Yes	Yes	Yes	Paralysis	Yes	Yes	Yes
(COPD) or Emphysema	No	No	No	Paralysis	No	No	No
(COPD) or Emphysema	No	No	No		No	No	No

Diabetes	Yes	Yes	Yes	Major Organ Transplant	Yes	Yes	Yes
Diabetes	No	No	No	Major Organ Transplant	No	No	No
	No	No	No		No	No	No

Depression	Yes	Yes	Yes	Chronic Fatigue Syndrome or	Yes	Yes	Yes
Depression	No	No	No	Fibromyalgia	No	No	No
	No	No	No	Fibromyalgia	No	No	No

Sleep Apnea	Yes	Yes	Yes	Narcolepsy	Yes	Yes	Yes
Sleep Apnea	No	No	No	Narcolepsy	No	No	No
	No	No	No		No	No	No

Cancer (Do not check “Yes” for Basal
Cell Carcinoma only)	Yes	Yes	Yes	Ulcerative Colitis or Crohn’s	Yes	Yes	Yes
	Yes	Yes	Yes	Ulcerative Colitis or Crohn’s	Yes	Yes	Yes
If “Yes”, Date of Diagnosis:	No	No	No	Disease	No	No	No
If “Yes”, Date of Diagnosis:
_______________________________
Psychotic, Psychiatric, Personality, or Bi-	Yes	Yes	Yes	Kidney Failure or Dialysis	Yes	Yes	Yes
Polar Disorder	No	No	No	Kidney Failure or Dialysis	No	No	No
Polar Disorder	No	No	No		No	No	No

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.

Form PA-9597 (CA)

Page 3 of 5

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.

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 (CA)

Page 4 of 5

Fraud

For your protection, California law requires the following to appear on this form: The falsity of any statement in the application for any policy shall not bar the right to recovery under the policy unless such false statement was made with the actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer.

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

	/		/
Child Signature		Date Signed
(Parent/Legal Guardian of the Child is

required to sign when submitting

dependent Evidence of Insurability on a

minor child.)

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 [email protected].

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries.

Form PA-9597 (CA)

Page 5 of 5

↓ Evidence Of Insurance PDF

File Specs

Fact Name	Description
Submission Deadline	The Evidence of Insurance form must be completed and submitted to The Hartford within 30 days of the signature date to avoid delays in processing.
Employer Responsibilities	Employers are required to fill out Sections 1 and 2 of the form and forward it to the employee. Accurate completion is essential.
Incomplete Forms	Submitting an incomplete form can lead to processing delays for the employee’s insurance request, emphasizing the importance of thoroughness.
Governing Law (California)	In California, the form is governed by state insurance laws which include specific requirements for disclosures and fraud prevention.
Medical Information Requirements	Each applicant must answer medical questions to the best of their knowledge. This information is crucial for assessing insurability.
Authorization of Information	The form includes an authorization section allowing The Hartford to access relevant medical information for underwriting purposes.

Evidence Of Insurance - Usage Guidelines

Completing the Evidence of Insurance form is a straightforward process that requires attention to detail. Once the form is filled out correctly, it should be submitted to The Hartford within 30 days of the date you sign it. This is important to ensure that your request for insurance is processed without delays.

Employer Details: In Section 1, print clearly the following information:

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 Number

Employee Details: In Section 2, also print clearly:

Employee Name (First, MI, Last)
Date of Hire (mm/dd/yyyy)
Base Annual Earnings
Coverage Effective Date (mm/dd/yyyy)

Life Coverage Requested: Fill in the dollar amounts for the following:

Current Life Coverage, including Guarantee Issue (GI)
Life Coverage Subject to Evidence of Insurability (EOI)
Employee Basic Life
Employee Supplemental or Voluntary Life
Spouse Basic Life
Spouse Supplemental or Voluntary Life
Child Supplemental or Voluntary Life

If applicable, check "Yes" if the employee is requesting Child Life coverage that is subject to EOI and indicate the number of children applying.
Applicant Information: Complete the details for each applicant:

First Name
Last Name
Social Security Number
Height
Weight
Date of Birth (mm/dd/yyyy)
Gender

Provide contact information for each applicant, including address, daytime phone, evening phone, and email address.
Medical Information: Each applicant must answer the medical questions honestly and to the best of their knowledge.
Authorization: Sign and date the authorization section to allow The Hartford to process the application.
Finally, mail the completed form to The Hartford Group Medical Underwriting at the specified address.

Once the form is submitted, The Hartford will review the information provided. If any additional details are needed, they may reach out for clarification. It’s essential to ensure that all sections are filled out accurately to avoid any delays in processing your insurance request.

Your Questions, Answered

What is the Evidence of Insurance form and why is it important?

The Evidence of Insurance form is a crucial document that verifies an employee's eligibility for life insurance coverage through their employer. It provides essential details about the employee and their dependents, along with their medical history. Completing this form accurately and submitting it within 30 days is vital, as any delays or inaccuracies can postpone the processing of insurance requests.

Who is responsible for filling out the Evidence of Insurance form?

The employer is responsible for completing the first two sections of the form, which include employer details and employee information. This ensures that the information provided is accurate and aligns with the company’s records. Once filled out, the employer must forward the entire form to the employee for completion of the remaining sections.

What happens if the Evidence of Insurance form is incomplete?

If the form is incomplete, it can lead to significant delays in processing the employee's insurance request. The Hartford requires all sections to be filled out clearly and accurately. An incomplete form can result in the need for additional information or even rejection of the application, causing frustration for both the employer and the employee.

What medical information is required on the Evidence of Insurance form?

The form requires detailed medical information from each applicant, including any diagnoses or treatments received within the past five years. Questions cover a range of health conditions, from chronic illnesses to recent surgeries. This information helps The Hartford assess the applicant's insurability and determine coverage eligibility.

How does the Evidence of Insurance form affect coverage for dependents?

The form allows employees to apply for coverage for their dependents, including spouses and children. If a child is applying for coverage, the form must indicate whether the child’s coverage is subject to Evidence of Insurability. This ensures that all family members are considered for insurance, but it also requires a thorough understanding of each dependent's health history.

What should I do if I have questions about the Evidence of Insurance form?

If you have questions or concerns about completing the Evidence of Insurance form, it’s best to reach out directly to The Hartford’s Customer Service Department. They can provide guidance and clarification on any aspect of the form. You can contact them toll-free at 1-800-331-7234 during business hours or email them at [email protected].

Common mistakes

Incomplete Sections: Failing to fill out all required sections, especially Section 1 and Section 2, can lead to delays. Each section must be completed clearly.
Illegible Handwriting: If the form is not printed clearly, it may cause confusion. Use block letters to ensure that all information is readable.
Incorrect Policy Number: Entering the wrong policy number can result in processing issues. Always double-check this information against your records.
Missing Signatures: Not signing the form or forgetting to have the required parties sign can halt the process. Ensure that all necessary signatures are included.
Incorrect Dates: Providing incorrect dates for hire or coverage can lead to complications. Verify that all dates are accurate and formatted correctly.
Failure to Provide Medical Information: Omitting answers to medical questions can delay approval. Answer all questions honestly and completely.
Not Keeping a Copy: Failing to retain a copy of the completed form for personal records can be problematic. Always keep a copy for your reference.

Documents used along the form

When submitting the Evidence of Insurance form, several other documents may be necessary to ensure a smooth processing of your insurance application. Each of these documents plays a vital role in providing additional information about your coverage and eligibility. Below is a list of common forms and documents that are often used in conjunction with the Evidence of Insurance form.

Employer Group Benefits Coverage Information: This form provides essential details about the employer's insurance policy and the employee's coverage options. It must be completed and submitted along with the Evidence of Insurance form.
Application for Life Insurance: This application collects personal information about the applicant, including health history and lifestyle choices, to assess eligibility for life insurance coverage.
Medical Authorization Form: This document grants permission for the insurance company to access the applicant's medical records. It is crucial for evaluating health-related risks associated with the insurance application.
Dependent Information Form: If the applicant is including dependents in their insurance coverage, this form collects necessary details about each dependent, such as their names and dates of birth.
Beneficiary Designation Form: This form allows the applicant to specify who will receive the insurance benefits in the event of their passing. It is important for ensuring that the intended beneficiaries are clearly identified.
Health Questionnaire: This document may be required to gather more detailed health information from the applicant. It helps the insurance company assess the risk involved in providing coverage.
Proof of Income: Some insurance policies may require proof of income to determine coverage amounts. This could include recent pay stubs or tax documents that verify the applicant’s earnings.

Completing and submitting these forms accurately will help facilitate the processing of your insurance application. If you have questions about any of these documents or need assistance, it’s always a good idea to reach out for support. Your peace of mind is important, and ensuring that all necessary paperwork is in order is a crucial step in securing your coverage.

Similar forms

The Certificate of Insurance is a document that outlines the coverage details of an insurance policy. Similar to the Evidence of Insurance form, it serves as proof that an individual is covered under a specific insurance policy. The Certificate of Insurance typically includes essential information such as the policyholder's name, the type of coverage, and the effective dates. Both documents aim to provide reassurance to employees or beneficiaries that they are protected under a particular insurance plan, offering clarity and peace of mind.

The Application for Life Insurance is another document closely related to the Evidence of Insurance form. This application is filled out by individuals seeking to obtain life insurance coverage. Like the Evidence of Insurance form, it requires personal details, medical history, and information about the desired coverage amount. Both documents play a crucial role in the insurance underwriting process, as they help insurers assess the risk associated with providing coverage to the applicant.

The Enrollment Form for Employee Benefits is similar in function to the Evidence of Insurance form, as it is used to enroll employees in various benefit programs offered by an employer. This form collects essential employee information and specifies the types of benefits being requested. Both documents are vital for ensuring that employees receive the coverage they need and that employers can effectively manage their benefits programs.

The Claims Form is another document that shares similarities with the Evidence of Insurance form. While the Evidence of Insurance form establishes coverage, the Claims Form is used to request benefits after a covered event occurs. Both documents require detailed information about the insured individual and the circumstances surrounding the claim or coverage. They serve as essential tools for navigating the insurance process, ensuring that individuals can access their benefits when necessary.

Finally, the Beneficiary Designation Form is akin to the Evidence of Insurance form in that it establishes who will receive benefits in the event of the policyholder's death. This form allows policyholders to specify their chosen beneficiaries, ensuring that their wishes are honored. Both documents are integral to the life insurance process, as they help clarify the terms of coverage and the distribution of benefits, ultimately providing peace of mind to policyholders and their loved ones.

Dos and Don'ts

When filling out the Evidence Of Insurance form, it is important to follow specific guidelines to ensure accuracy and timely processing. Below is a list of things you should and shouldn't do:

Do: Complete all sections of the form thoroughly.
Do: Print clearly to avoid any misinterpretation of your information.
Do: Double-check the accuracy of all details, especially policy numbers and contact information.
Do: Submit the form within 30 days of the signature date to prevent delays.
Don't: Leave any sections blank; incomplete forms will delay processing.
Don't: Use abbreviations or shorthand that may confuse the reader.

Misconceptions

Evidence of Insurance is only for new policies. Many believe this form is only necessary when applying for new insurance. In reality, it is also used for existing policies when requesting changes or additional coverage.
Only employees need to complete the form. Some think that only the employee's information is required. However, employers must also fill out specific sections to ensure proper processing.
Incomplete forms can be submitted. There's a misconception that submitting an incomplete form is acceptable. In fact, any missing information can delay the processing of the insurance request.
Medical information is optional. Some applicants may think that providing medical information is not necessary. However, accurate medical disclosures are critical for the underwriting process.
The form can be submitted anytime. Many assume they can submit the form whenever they wish. It is essential to submit it within 30 days of the signature date to avoid delays.
Once submitted, no further communication is needed. Some believe that after submission, they will not need to communicate further. In reality, the insurance company may reach out for additional information or clarification.

Key takeaways

Complete All Sections: Ensure that all sections of the Evidence of Insurance form are filled out completely. This includes both the Employer and Employee details.
Submission Deadline: Submit the completed form to The Hartford within 30 days of the signature date to avoid delays.
Employer Responsibilities: Employers must fill out Section 1 and Section 2 accurately and provide the form to the employee.
Accurate Information: Use your policy and employee records to provide accurate details. Incomplete information can lead to processing delays.
Medical Information: Each applicant must answer all medical questions truthfully. A Legal Guardian must answer for minor children.
Authorization: The applicant must authorize The Hartford to contact them for additional information or clarification during the evaluation process.
Changes in Medical Condition: Notify The Hartford in writing of any changes in medical conditions between signing the form and approval of coverage.
Privacy of Information: Personal health information will be treated confidentially and used only for underwriting purposes.
Contact Information: If you have questions, reach out to The Hartford’s Customer Service Department for assistance.