Application for Group Disability Income Insurance

AGP-5836

Underwritten by Hartford Life and Accident Insurance Company
Hartford, Connecticut 06155

Required fields are marked with a blue asterisk.*

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Personal Information
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  9. Have you been actively engaged in the full-time duties of your occupation (at least 30 hours per week) immediately before the date of this application? *
     
  1. Do you have any Disability Income Insurance in force or pending in this or any other company? *
     

    If Yes, provide details in the fields provided.

  2. Company 1
    1. Is this insurance to be replaced?
  3. Company 2
    1. Is this insurance to be replaced?
  4. Other Companies
Coverage Requested
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  5. Is the Monthly Benefit Amount herein applied for equal to or less than 60% of your Pre-Disability Earnings minus any Other Income Benefits? *
     

PLEASE ANSWER THE FOLLOWING AND GIVE DETAILS OF ALL "YES" ANSWERS.

  1. 1. In the past 10 years have you been diagnosed or treated by a member of the medical profession for:
    1. A. A heart murmur, high blood pressure, stroke, or any disease or disorder of the heart, blood or circulatory system? *
       
    2. B. Asthma, shortness of breath, tuberculosis or any disease or disorder of the lungs or respiratory system? *
       
    3. C. Colitis, ulcer, liver, kidney disease, or any disease or disororder of the digestive, urinary or reproductive system? *
       
    4. D. Alcoholism, drug abuse, severe headaches, epilepsy, dizziness or any disease or disorder of the brain or nervous system including mental or emotional disorders? *
       
    5. E. Cancer, tumor, diabetes, blood or sugar in urine, or any disease or disorder of the glands? *
       
    6. F. Arthritis, impaired sight or hearing, or any disease or disorder of the skin, bones, or joints, including neck or back disorders? *
       
    7. G. Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder? *
       
    1. 2. During the past 5 years have you consulted any physician, surgeon, psychologist, psychiatrist or other practitioner for any reason not previously noted on this application; or been confined or treated in any hospital, sanatorium or similar institution? *
       
    1. 3. Are you now pregnant? *
       
Attestation & Consent

Please read and accept the following documentation.

TERMS OF SERVICE
IMPORTANT
PLEASE READ THIS ENTIRE AGREEMENT CAREFULLY

You must agree to these Terms of Service ("Agreement") in order to enter into an insurance transaction or transaction with your American College of Emergency Physicians on this website. Please read this Agreement carefully.

HBI provides this Website, the materials and services located at www.haganbarron.com and under the name HBI (collectively "Website" or "Site") to you as a user conditioned upon and subject to your acceptance of this Agreement. By using and/or accessing this Site or its services, you acknowledge that you have read, understand, and agree to be legally bound by this Agreement. You will be asked to confirm your acceptance of this "Agreement" by clicking "I Accept" on the Website.

1. Disclosures & Consent to Electronic Transactions / Electronic Signature

a. By entering this Website and agreeing to be bound by this Agreement, you are providing your affirmative consent to the use of an electronic signature to authenticate the insurance transaction in electronic form. You understand and agree that the insurance company will rely on your electronic signature to process and effect insurance transactions.

b. You acknowledge that you understand that you are not obligated to enter into transactions electronically and that you have a right to conduct insurance transactions in paper format if you wish. By entering this Site and agreeing to be bound by this Agreement, you affirmatively consent to conduct transactions in electronic form. If you wish to conduct insurance transactions in paper form, please contact your association/policyholder or its representatives. There is no charge to you for requesting a paper transaction.

c. Please contact HBI at 1-800-456-0737 if you would like us to mail you a paper copy of your insurance elections for your records because you will not be able to access your enrollment information on the Site after your enrollment. If you wish to confirm or make changes to your coverage or beneficiary elections after your enrollment, you must contact your association/policyholder. You understand and agree that requests for change submitted to The Hartford or the Site will not be valid or take legal effect after the end of your enrollment.

d. Once you have given consent for an electronic transaction, you may withdraw your consent only if The Hartford has not taken action in reliance on your consent. To update your contact information or to withdraw your consent to an electronic transaction, you may contact your association/policyholder/Administrator. You may contact HBI by calling 1-800-456-0737 or writing to HBI at: 1741 S. Cleveland Ave., Suite 303, Sioux Falls, SD. 57103. There is no fee charged for such 2 requests. However, your withdrawal of consent shall not diminish the legal effectiveness or enforcement of any transaction agreed to prior to your withdrawal of consent. If you withdraw consent after your enrollment, your insurance will remain effective until your request for cancellation is received by the group policyholder or its representative.

e. You agree that your electronic signature authorizes The Hartford or its authorized representatives:

(1) to process this insurance transaction at your request and any future transactions that may be needed to administer and help keep in force your coverage under the insurance policy. For example, we will rely on your electronic signature to authorize us to process your request for insurance coverage(s) and beneficiary designation(s) made during your enrollment.

(2) to process, as applicable:

i. a billing transaction, including but not limited to: processing a payment by credit card using the credit card number you have provided; processing an electronic bank draft using the checking account number you have provided; or sending you a billing statement at the address you have provided; or

ii. a billing transaction with your financial institution to deduct the appropriate amount from your account.

(3) to communicate with you by mail, telephone or electronically by sending to you communications including, but not limited to, any and all types of electronic communication by email, fax, mail and telephone.

f. [You understand and agree that to access the Website to view your enrollment elections, you will need the following hardware and software: Microsoft Windows or Macintosh compatible computer, Internet access, a working email address, an Internet Browser (Internet Explorer version 6 or higher, Safari, Firefox).] Or [After you enroll, you understand and agree that you will not have access to your electronic enrollment record. You may print a confirmation of your enrollment election at the time of enrollment, or you may contact your association/policyholder/Administrator for confirmation after your enrollment period ends.]

2. Additional Terms and Conditions

HBI provides information and services on this Website, and all layouts, materials, designs, and images on this Website are copyrighted or proprietary to HBI its affiliated companies and/or third party service providers. As a condition of your use of this Website and the services, you agree that you will not use the contents of this Website in any other website or in a network computer environment. All uses of this Website apart from educational, informational and enrollment purposes are strictly prohibited.

In addition, as a further condition of your use of this Website and the services, you agree that you will not use the Website or services to infringe the intellectual property rights of HBI in any way; use the Website or services to modify or manipulate the 3 Website or services or any of HBI’s hardware or software to invade the privacy of, or obtain private information concerning any enrollee or applicant of The Hartford, or to erase or damage any information contained on the computer or the information of any user connected to this Website or the services, or to reveal any portion of this Website or the services. Furthermore, you agree that you will not use the Website or services to introduce viruses, worms, Trojan horses or other destructive or harmful codes, and you agree that you will take every precaution not to introduce these harmful codes into the Website and services.

You agree that the materials and services on this Website are provided "as is" and for informational purposes only. You understand that neither The Hartford nor HBI makes any representations or warranties that the materials are suitable for your needs, are complete, timely, reliable, or are free from errors, inaccuracies or typographical mistakes. The information contained on this Website was believed to be accurate at the time it was placed on the Website. The Hartford and HBI periodically update the information on the Website, but disclaim any responsibility to do so. Therefore, you understand and agree that The Hartford and HBI take no responsibility for the timeliness, accuracy or applicability of the information at the time it may be accessed and that The Hartford and HBI disclaim all warrant ies, express or implied, including, but not limited to, implied warranties of merchantability of fitness for a particular purpose or of non-infringement of other's rights.

You understand and agree that neither The Hartford nor HBI is engaged in rendering legal, tax, insurance benefits or any other advice through this Website or services. Your insurance needs are highly individual, and The Hartford and HBI do not represent themselves as giving financial advice or advice on your individual insurance needs through this Website and services. You understand and agree that you should consult your own attorney and financial advisor(s) for advice in these areas.

You understand and agree that the information on The Hartford's insurance products as described in this Website is not complete and does not change or affect the insurance policies as actually issued. Although you have been provided with a description of benefits, you understand that only the insurance policy issued to the policyholder (your association) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the information on the Website and services, the benefit highlights, and the insurance policy, the terms of the insurance policy apply.

You understand and agree that insurance will not be valid or in force with respect to you or your dependents if any such person is not eligible in accordance with the terms of the group policy issued to your association/policyholder. You acknowledge and agree that if group participation requirements are not met, the insurance policy will not be issued and the elected coverage(s) will not be in force.

If you choose not to accept these Terms of Service, you will not be enrolled. You acknowledge that you have received and read HBI Privacy Policy and Legal Notice.



THE HARTFORD'S FRAUD STATEMENT

A person commits a fraudulent insurance act if that person knowingly and with intent to defraud any insurance company or other person either (a) files an application for insurance or statement of claim containing any materially false information, or (b) conceals information concerning any material fact in order to obtain an insurance policy or benefit under an insurance policy. A fraudulent insurance act is a crime. (In Oregon, a fraudulent insurance act may be a crime.) The Hartford shall pursue prosecution of any fraudulent insurance act to the fullest extent of the law. Residents of Florida, New Jersey, Arkansas, New Mexico, California, Colorado, Louisiana, New York, Pennsylvania, Puerto Rico and Virginia.

STATE SPECIFIC FRAUD LANGUAGE

For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement or claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

For residents of New Jersey, Arkansas, and New Mexico: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

FOR RESIDENTS OF CALIFORNIA: FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or its agent who knowingly provides false, incomplete, or misleading information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to an insurance settlement or award shall be reported to the Colorado Division of Insurance.

For residents of Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects a person to criminal and civil penalties.

For residents of Puerto Rico: Any person who knowingly and with the intent to defraud, presents false Information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.

For residents of Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

 

ATTESTATION

By clicking 'I Accept':

I attest that I am presently a bona fide member in good standing of American College of Emergency Physicians and am therefore eligible to enroll for Disability insurance offered by American College of Emergency Physicians. I understand that attesting that I am a member of American College of Emergency Physicians when I am not currently a member is a misrepresentation and could constitute a fraudulent statement pursuant to state statutes as described in the Fraud Statement above.
  • I agree to the Terms of Service for this product.
  • I am providing my affirmative consent for the use of an electronic signature to authenticate enrollment for this Service in electronic form.
  • I/we understand that coverage will become effective only after approval by the Company and receipt of the first payment of premium. I/we acknowledge that the Application is true and accurate for each person to be insured.
  • I/we acknowledge that I/we have read and agree to the Certification and Authorization language.
 

Authorization

Please read and acknowledge the following authorization text by checking the acknowledgement box.

I hereby certify that I have read or have had read to me all statements and answers in this application, and in any other application or medical form required by the Company, and that they are full, complete, and true to the best of my knowledge and belief. I also understand that any misrepresentation contained herein or relied on by the Company may be used to reduce or deny a claim or void the contract within the contestable period if such misrepresentation materially affects the acceptance of the risk. I understand that any intent to defraud or knowingly facilitate a fraud against the Company, by submitting an application or filing a claim containing a false or deceptive statement is insurance fraud. I also agree that a copy of this application shall be attached to and form a part of any certificate issued. I also understand that the Company may request whatever additional evidence of insurability it needs.

Subject to the deferred effective date provision I understand that coverage will not become effective until the Company grants its underwriting approval. I do not receive temporary or conditional insurance coverage just because I submit an application and pay the first premium.

I authorize any: doctor or counselor; health practitioner; hospital, clinic or medical facility; insurer or reinsurer; consumer reporting agency; Medical Information Bureau, Inc.; or employer; to give Hartford Life and Accident Insurance Company or its legal representative information about my physical or mental health, (including history, condition, diagnosis and treatment), drug or alcohol use history, other insurance coverage or employment status.


Hartford Life and Accident Insurance Company will use the information to decide if and to what extent I am eligible for insurance coverage or benefits under the policy. This information will be treated as confidential. I understand the Medical Information Bureau, Inc. will release records or information only to Hartford Life and Accident Insurance Company.

I authorize Hartford Life and Accident Insurance Company to give information about me to: its reinsurer(s), the Medical Information Bureau, Inc., any other insurance company to whom I may apply for Life or Health Insurance, or other persons or organizations handling a claim, underwriting coverage applied for or administering coverage issued as a result of this application or as required by law.


I understand that upon written request I may revoke this authorization except to the extent that action has already been taken in reliance on the authorization. This authorization expires two (2) years from the effective date of my coverage or, if no coverage has been issued one (1) year from the date of this application.

I understand that a photocopy of this form is as valid as the original, and that I have a right to receive a copy of this form upon request.

I certify that I have received the Notice of Insurance information Practices.

I understand that any injury or sickness, diagnosed or undiagnosed, for which I have received medical advice or treatment in the 12 month period prior to my effective date of coverage will not be covered until I have gone 12 months ending on or after my effective date of coverage without medical advice or treatment for that condition, or until two (2) years after my effective date of coverage, whichever comes first, provided that the condition is not specifically excluded or limited by the policy or by a Health Waiver attached to my certificate. Applications to increase coverage will be subject to a new pre existing conditions limitation.

I further understand that any condition excluded or limited by the policy or by a Health Waiver attached to my certificate will not be covered under this policy at any time.

BY INSERTING MY NAME IN THE SPACE PROVIDED, I ACCEPT THE AUTHORIZATION, AND THE ATTESTATION & CONSENT.

 
 

    I wish to pay my premiums: *
     
Notices

Please read the following notice.

STATE NOTICE

Any person who includes any false or misleading information on an application or filing a claim for an insurance policy is subject to criminal and civil penalties. It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. In certain states, penalties may include imprisonment, fines, denial of insurance, and civil damages.

Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the State Insurance Regulatory Agency and/or Division of Insurance. If while in the state of Florida, a person knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information, the person is guilty of a felony in the third degree. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false, misleading or deceptive information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to substantial civil and/or criminal penalty where and to the extent allowed by state law.

Finish

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DI2016

Form SRP-1311 AP (A) (HLA)

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