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Notice of Continuation of Coverage

As a terminated employee – or as an active employee or retiree – losing coverage or a portion of coverage under your

employer’s Group plan, you may be eligible to continue all or a portion of that coverage without submitting evidence of good

health. Potential options are explained below. The specific options available to you are based on the provisions as defined in

the Group plan. Included with this notice is a form you can submit to obtain additional information. You will receive details on

the specific coverage options available to you, rates, and the necessary forms to enroll.

Standalone Accidental Death and Dismemberment (SAAD&D) Conversion

Under this conversion option, you may convert your Employer Group Standalone Accidental Death and Dismemberment

coverage to a group conversion policy. Subject to certain limitations and exclusions, this policy covers you against death and

dismemberment caused by an accident, 24 hours a day anywhere in the world, whether you are traveling or are at work or play.

The Principal Sum you elect to convert cannot exceed the lesser of the Principal Sum you carried under your group plan or the

state maximum shown

below.

Coverage automatically decreases to $25,000 upon reaching age 70 and to $12,500 upon

reaching age 75. The conversion option may be available to your dependents if you carried dependent coverage under your

employer’s group plan. Premiums for a Standalone Accidental Death and Dismemberment Conversion policy are higher

than your Employer Group plan rates.

Non-NY Residents may choose any amount between $25,000 and $250,000 in $1,000 increments. Rates increase upon

reaching age 75 but you are not subject to an age limit.

NY Residents ONLY may choose any amount between $10,000 and $100,000 in $10,000 increments. Rates will not increase

and you are not subject to an age limit.

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Attached is a form that contains additional information about continuing coverage. You can use this to request a quote and the

necessary forms to enroll.

Please note that there is a designated timeframe during which you can exercise your coverage continuation options. To

continue coverage, you must mail or fax this form to request information within 15 days from the date of this notice or 31

days from your group coverage termination date, whichever is later. Under no circumstances, however, will

continuation of coverage be available beyond 91 days from your group coverage termination date. Any issues

regarding late notification by your employer must be addressed with the employer.

If you have questions about this information, your eligibility, or the status of any request you have submitted, please call a

representative at 1-877-320-0484.

The Hartford, Portability and Conversion Unit

P.O. Box 248108

Cleveland, OH 44124-8108

Fax 1-440-646-9339

GR-10671-22

8-09

Form Gr-10671-22 - Notice Of Continuation Of Coverage - The Hartford - Portability And Conversion Unit