The Hartford Coverage Form Download

Exercise your right to continue your insurance coverage using the forms below.

Why You're Here

You enrolled in one, or more, of the following coverage(s), offered by your employer (or other group):

group accident insurance plan,
group critical illness insurance plan (also called group specified disease insurance in NY),
group hospital indemnity insurance plan,
group accidental loss of life and severe injury benefits (standalone accidental death and dismemberment (SAADD)), or
group long term disability plan.

The employer group plan included an "Extended Continuation" provision and/or a "Portability" provision.

Who Is Eligible?

Extended Continuation: Anyone insured under the group policy(ies) at the time of the qualifying event may be eligible under the extended continuation provision. Your coverage tier may change (from what you had as an active employee/member under the plan) based on who is eligible when you request extended continuation.
Portability: Insurance through The Hartford’s group portability policy is available when a qualifying event under a Group Critical Illness, Group Accident or Group Hospital Indemnity insurance plan offered by an employer (or other group) ends. Please see the Portability provision in the prior group plan for specific details.

What You Need to Do

Click on the applicable Continuation or Portability buttons below to access the form(s).
Print and complete the form(s).
Include your initial payment when you mail your form(s). As an option for future payments, use the Automatic Payment Option (APO) form to request automatic premium deductions from your account.
Return your form(s) and your payment form to:
The Hartford Portability & Conversion Unit
PO Box 43786
Cleveland OH 44143-0786

Timeliness Is Important

Your request form and initial premium payment should be submitted within 91 days from the date insurance under the group policy(ies) would otherwise end. In any event, a request for continuation received more than 91 days after insurance under the group policy(ies) would otherwise end will not be accepted.

Step 1.

EXTENDED CONTINUATION

Download the appropriate form(s), complete it, and return it with premium to continue your Group Critical Illness (CI), Group Accident (AI), Group Hospital Indemnity (HI), Group Accidental Loss of Life and Severe Injury Benefits (SAADD), and/or Group Long Term Disability (LTD) insurance. One form can be used for all CI, AI, and HI insurances, and a separate form is used for SAADD or LTD. Questions regarding your coverage tier, amounts, or premiums should be directed to your former employer.

PORTABILITY

Download the appropriate form(s), complete it and return it with premium payment to port your Group Critical Illness, Group Hospital Indemnity, and/or Group Accident Insurance. Questions regarding these forms can be directed to The Hartford at 877-320-0484.

Group Critical Illness Insurance

Group Critical Illness Insurance (CI) provides a financial, lump-sum benefit to employees upon diagnosis of a covered illness. These covered illnesses are typically very severe and likely to render the affected person incapable of working. Because of the financial strain these illnesses can place on individuals and families, critical illness insurance is designed to help ill employees pay the mortgage, seek experimental treatment, or handle unexpected medical expenses.

Group Accident Insurance

Group Accident Insurance (AI) helps protect against the financial burden that accident-related costs can create. Accident Insurance from The Hartford complements other benefits, including traditional healthcare insurance. When it’s combined with Voluntary Critical Illness it offers employees an affordable, complete benefits package without undue expense to the employer.

Group Accidental Loss of Life and Severe Injury Benefits (Accidental Death and Dismemberment)

Group Accidental Loss of Life and Severe Injury Benefits Insurance (SAADD) provides cash benefits for accidental loss of life, limb, and other specific severe injuries that can help you and your loved ones manage expenses and carry on with productive lives following a covered accident.

Group Hospital Indemnity

Group Hospital Indemnity Insurance (HI) provides cash benefits for each day an employee is confined in a hospital for a covered illness or injury. Insureds can use these benefits to help safeguard against the expenses that medical insurance may not cover like co-pays, deductibles, or any other living expense that may arise. Designed to help employers fill in the financial gaps left by most of today’s high-deductible health plans (HDHPs), Group Hospital Indemnity Insurance can be a meaningful addition to any employee benefits offering.

Long Term Disability

Group Long Term Disability insurance can help provide stability in an unstable time, by replacing part of your income and helping to cover your day-to-day living expenses, if you are unable to work for an extended period of time due to illness or injury.

The Hartford Financial Services Group, Inc., (NYSE: HIG) operates through its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company, under the brand name, The Hartford®, and is headquartered at One Hartford Plaza, Hartford, CT 06155. For additional details, please read The Hartford’s legal notice at www.TheHartford.com. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

CONTINUE YOUR COVERAGE

Critical Illness Insurance | Accident Insurance | Hospital Indemnity Insurance | Accidental Loss of Life and Severe Injury Benefits | Long Term Disability Insurance