Form Gr-10671-16 - Notice Of Continuation Of Coverage Page 3
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Notice of Continuation of Coverage
Employer:____________________________________________ Policy #:_______________________
The following information is to be completed by Employer or Employer Representative
Employee Name:____________________________________ Employee ID#:_______________ Date:__________________
Last Day Worked (or date employee is no longer in an eligible class):_____________________________________________
Date of Group Coverage Termination:___________________ Termination Reason:__________________________________
Signature________________________________________ Print Name___________________________________________
Email Address__________________________________________ Telephone_____________________________________
As noted above, Conversion and Portability options are available without submission of evidence of good health. The rates for
Life Conversion will be substantially higher than your employer Group plan rates. The rates for Portability are based on the
employer’s standard industry code and/or Group plan provisions and may be higher than your employer Group rates. Portability
rates increase every 5 years (years in which your age on your birthday ends in 5 or 0).
Life Conversion and Portability rates are quoted and billed quarterly.
Employee: To request specific rates and enrollment information, please complete the information below and mail or
fax this entire page to:
The Hartford, Portability and Conversion Unit, P.O. Box 248108, Cleveland, OH 44124-8108
Fax 440-646-9339, Phone 877-320-0484
Yes, I am interested in receiving the information checked below.
Life Conversion Quote
Portability Enrollment Form
Please print the following information:
Name:____________________________________________ Date of Birth:_____________________________________
Social Security # (indicate last 4 digits only):_____________________________________________________________
Address:___________________________________________________________________________________________
City:________________________________________ State: _______________ Zip Code:_________________________
Telephone Number:_________________________________________ Email:___________________________________
I am interested in receiving information for the following persons:
Myself
My Spouse
My Child(ren)
Please print the name(s), relationship, and date(s) of birth for each dependent who may be eligible for coverage.
Include an additional sheet if necessary.
Name:___________________________________ Relationship:________________ Date of Birth:_____________________
Name:___________________________________ Relationship:________________ Date of Birth:_____________________
Name:___________________________________ Relationship:________________ Date of Birth:_____________________
Name:___________________________________ Relationship:________________ Date of Birth:_____________________
I understand that I have only 31 days from the date of my group coverage termination OR 15 days from the date of this
notice, whichever is later, to complete and submit this form to The Hartford. In no event, however, will my eligibility to
continue coverage exceed 91 days from my group coverage termination date.
___________________________________________________
___________________________________
Signature (required)
Date
GR-10671-16
3
11-12
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