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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_____________________________________

The rates for Standalone AD&D Conversion will be higher than your employer Group plan rates. Standalone AD&D Conversion

rates are quoted annually and billed annually or semi-annually.

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.

SAAD&D Conversion

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:_____________________

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-10671-22

8-09

Form Gr-10671-22 - Notice Of Continuation Of Coverage - The Hartford - Portability And Conversion Unit Page 3