Evidence Of Insurance – Fill Out and Use This PDF

The Evidence of Insurance form is a crucial document for employees seeking to enroll in or make changes to their employer-provided insurance coverage. It is used to confirm personal and medical information that determines eligibility for insurance offered by The Hartford. All sections must be filled out accurately and submitted within a set timeframe to avoid delays in processing.

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Evidence Of Insurance PDF Details

When individuals or families make decisions regarding insurance, particularly through employer-sponsored benefits, the process requires thorough attention to detail and compliance with specific instructions. The Evidence Of Insurance form serves as a critical step in this process, ensuring that the necessary coverage information is meticulously captured and relayed accurately. The form, which must be filled out by both employers and employees, initiates with Employer Group Benefits Coverage Information, asserting the importance of choosing a reliable insurance provider such as The Hartford. Employers are tasked with the completion of sections dedicated to their details and those pertaining to the employee, including policy numbers, earnings, and coverage details—highlighting the dual responsibility in the documentation process. Adding another layer of complexity, the form requires information on the Life Coverage requested and subjects it to Evidence of Insurability (EOI), showing the nuanced considerations in determining coverage eligibility. Moreover, detailed medical questions aim at scrutinizing the health status of the applicants, covering a range of diagnoses and treatments which could influence the underwriting outcome. This comprehensive approach underscores the insurance industry's meticulous measures to balance risk with the provision of benefits, emphasizing the form's role in facilitating informed and judicious insurance coverage decisions.

Question	Answer
Form Name	Evidence Of Insurance
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	hartford eoi online, hartford life insurability form, hartford insurability eoi online, hartford insurability

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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 medical.uw@thehartford.com.

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

Form PA-9597 (CA)

Page 5 of 5

How to Edit Evidence Of Insurance Online for Free

We've applied the hard work of our best computer programmers to build the PDF editor you are going to benefit from. Our application allows you to complete the hartford evidence insurability form without any difficulty and don’t waste precious time. Everything you should undertake is try out the next easy-to-follow rules.

Step 1: To begin, press the orange button "Get Form Now".

Step 2: Once you've entered the hartford evidence insurability editing page you may see each of the functions you can carry out regarding your document within the top menu.

Feel free to provide the following details to complete the hartford evidence insurability PDF:

entering details in hartford evidence of insurability form part 1

Enter the expected data in the space Section Employee Details to be, Employee Name First MI Last, Base Annual Earnings, As described in the contract with, Date of Hire mmddyyyy, Coverage Effective Date mmddyyyy, Life Insurance Coverage Requested, even if the employee is not, Enter the dollar amount of Life, GI is the maximum amount of, Current Life Coverage including GI, Life Coverage Subject to EOI, Employee Basic Life, Employee Supplemental or Voluntary, and Spouse Basic Life.

Filling out hartford evidence of insurability form step 2

You should emphasize the relevant data within the Weight lbs If currently pregnant, Male Female, Male Female, Male Female, Day Time Phone, Evening Phone, Email Address, Day Time Phone, Evening Phone, Email Address, Day Time Phone, Evening Phone, Email Address, EE Address, and SP Address box.

Completing hartford evidence of insurability form step 3

The Medical Information Each Applicant, Within the past years have you, Are you currently pregnant, Within the past years with the, Within the past years have you, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, and Yes No section needs to be used to record the rights or responsibilities of each party.

hartford evidence of insurability form Medical Information Each Applicant, Within the past years have you, Are you currently pregnant, Within the past years with the, Within the past years have you, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, and Yes No fields to fill out

Fill out the template by taking a look at the next fields: Blocked Arteries Arteriosclerosis, Stroke or transient ischemic, Chronic Obstructive Pulmonary, Diabetes, Depression, Sleep Apnea, Cancer Do not check Yes for Basal, If Yes Date of Diagnosis, Yes No, Yes No, Yes No, Yes No, Yes No, Yes No, and Yes No.

stage 5 to filling out hartford evidence of insurability form

Step 3: When you choose the Done button, your prepared document can be exported to each of your devices or to email specified by you.

Step 4: Create copies of the document - it may help you refrain from upcoming troubles. And don't be concerned - we don't disclose or look at your data.

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