Form Gr-10671-18 - Notice Of Continuation Of Coverage

Download a blank fillable Form Gr-10671-18 - Notice Of Continuation Of Coverage in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Gr-10671-18 - Notice Of Continuation Of Coverage with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Notice of Continuation of Coverage

As a terminated employee – or as an active employee or retiree – losing coverage or a portion of coverage for you and/or your

dependents under your employer’s Group plan(s), 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.

Based on your selection, you will receive a personalized quote, details on the specific coverage options available to you, and the

necessary forms to enroll.

Life Conversion

The Life Conversion option provides the opportunity for you to obtain an individual life insurance policy that accumulates cash

value and is offered at individual insurance rates. There are no mandatory age reductions and coverage can continue with

premium payment until the Scheduled Maturity Date (age 120) at which time the cash surrender value is paid to the insured.

If coverage is ending because The Hartford Group Life policy is terminating or coverage for a class of employees is terminating,

some restrictions may apply. If coverage is ending for any other reason, you can generally convert up to the full amount of your

terminating coverage. Conversion is also available to your dependents if they had coverage under your group plan. You may

have the option to obtain an 11-month term policy prior to the permanent life policy becoming effective. Please refer to The

Hartford Group Life policy for information. Premiums for a Life Conversion policy are substantially higher than your

Employer Group plan rates.

Portability

Under the Portability option you may obtain a group life insurance policy to continue 100%, 75%, or 50% of the amount of life

insurance coverage (Basic, Supplemental, or both) you had under your Group plan up to a maximum amount, generally

$250,000 depending upon the provisions of your Group plan. The Portability policy provides group term coverage and is

available to you provided you have not yet reached your Social Security full retirement age. The Portability option may also be

available to your dependents if you carried dependent coverage under your employer’s group plan and if the group plan includes

portability as an option for dependents. The amount of coverage you elect to port is reduced by 75% at age 65 and coverage

terminates at age 75. Portability is not available if your employer is terminating the group plan. Additional restrictions may also

apply. Premiums for a Life Portability policy may be higher than your Employer Group plan rates and rates increase

every five years (years in which your age on your birthday ends in 5 or 0).

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.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company, Hartford Life and Accident

Insurance Company and Hartford Life and Annuity Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of

both companies is Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail

exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

GR-10671-18

04-12