Evidence Of Insurance PDF Details

It is no secret that having insurance can provide peace of mind in the event of an unexpected accident or tragedy. However, many people do not know that evidence of insurance can be required in order to protect oneself in certain situations. This article will explore some instances where proof of insurance may be necessary and provide tips on how to keep this important document on hand.

The listing features details about the evidence of insurance. You'll have the projected time it might take you to fill out the form and several additional details.

QuestionAnswer
Form NameEvidence Of Insurance
Form Length5 pages
Fillable?Yes
Fillable fields148
Avg. time to fill out30 min 55 sec
Other nameshartford life insurability form, hartford insurability eoi online, hartford evidence insurability, hartford insurability form get

Form Preview Example

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

$

 

$

 

 

 

 

 

 

 

Spouse Basic 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,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(check one)

 

pre-

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CH Address:

 

 

 

 

Day Time Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening Phone:

 

 

 

 

same as EE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

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)?

No

No

No

 

 

 

 

 

 

 

 

Are you currently pregnant?

 

 

 

 

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?

 

 

 

 

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

No

No

No

groups), or been convicted of operating a motor vehicle while under the influence of drugs or alcohol?

 

 

 

 

 

 

 

 

 

 

 

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

Joint, Ligaments, Knee, Back,

No

No

No

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

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

 

 

 

 

 

 

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

(ALS) or Multiple Sclerosis

No

No

No

No

No

No

Blood Clot)

(MS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stroke or transient ischemic attack (TIA)

Yes

Yes

Yes

Alzheimer’s or Parkinson’s

Yes

Yes

Yes

No

No

No

Disease

No

No

No

 

 

 

 

 

 

 

 

 

Chronic Obstructive Pulmonary Disease

Yes

Yes

Yes

Paralysis

Yes

Yes

Yes

(COPD) or Emphysema

No

No

No

No

No

No

 

 

 

 

 

 

 

 

 

Diabetes

Yes

Yes

Yes

Major Organ Transplant

Yes

Yes

Yes

No

No

No

No

No

No

 

 

 

 

 

 

 

 

 

 

Depression

Yes

Yes

Yes

Chronic Fatigue Syndrome or

Yes

Yes

Yes

No

No

No

Fibromyalgia

No

No

No

 

 

 

 

 

 

 

 

 

Sleep Apnea

Yes

Yes

Yes

Narcolepsy

Yes

Yes

Yes

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

 

If “Yes”, Date of Diagnosis:

No

No

No

Disease

No

No

No

 

 

 

 

 

 

 

_______________________________

 

 

 

 

 

 

 

Psychotic, Psychiatric, Personality, or Bi-

Yes

Yes

Yes

Kidney Failure or Dialysis

Yes

Yes

Yes

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 eoi form 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 eoi form 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 eoi form PDF:

entering details in evidence of insurability form the hartford part 1

Enter the expected data in the space BaseAnnualEarnings, CoverageEffectiveDatemmddyyyy, CurrentLifeCoverage, includingGI, LifeCoverageSubjectto, EOI, EmployeeBasicLife, EmployeeSupplementalorVoluntaryLife, SpouseBasicLife, SpouseSupplementalorVoluntaryLife, and ChildSupplementalorVoluntaryLife.

Filling out evidence of insurability form the hartford step 2

You should emphasize the relevant data within the Indicatethenumberofchildrenapplying, and Pageof box.

Completing evidence of insurability form the hartford step 3

The MaleFemale, MaleFemale, MaleFemale, DayTimePhone, EveningPhone, EmailAddress, DayTimePhone, EveningPhone, EmailAddress, DayTimePhone, EveningPhone, EmailAddress, EEAddress, SPAddress, and sameasEE section needs to be used to record the rights or responsibilities of each party.

evidence of insurability form the hartford MaleFemale, MaleFemale, MaleFemale, DayTimePhone, EveningPhone, EmailAddress, DayTimePhone, EveningPhone, EmailAddress, DayTimePhone, EveningPhone, EmailAddress, EEAddress, SPAddress, and sameasEE fields to fill out

Fill out the template by taking a look at the next fields: YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, YesNo, HeartRelatedSurgeryorHeartAttack, YesNo, and YesNo.

stage 5 to filling out evidence of insurability form the hartford

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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