How Do I Apply?

1. Print and complete the Application and answer all questions in full. Sign your name and date the Application. Your Application is subject to approval by Hartford Life Insurance Company.

2. Mail your completed Application to: Association Services, Hillsboro Executive Center North, 350 Fairway Drive, Suite 200 Deerfield Beach, FL 33441-1834

3. Don't send any money now; you will be billed later once your Application is approved.

When your Application is approved, you'll receive your Certificate of Insurance. You'll then have 30 days to review the Plan and decide if it's the coverage for you.

Acceptance into this plan is subject to medical evidence of insurability as determined by Hartford Life Insurance Company. Depending on your age, the amount of coverage you request, and your answers on the application, a medical examination, medical test(s), or other evidence of good health may be required. Any exams/tests requested by the company will be conducted at your convenience and at no expense to you.

PLEASE SEND NO MONEY NOW; YOU WILL BE BILLED AFTER YOUR APPLICATION IS APPROVED.

Please feel free to contact Insurance Administration, if you have any questions regarding this plan. The toll-free number is: 1-800-221-2168 (extension 4).

Notice of Insurance Information Practices

Your application is our major source of information. However, Hartford Life Insurance Company may also collect or verify information by contacting individuals or organizations which have information or records about you or others to be insured.

Information regarding your insurability will be treated as confidential. Such information will not be disclosed to others without your authorization, except to the extent necessary for the conduct of our business. Hartford Life Insurance Company or its reinsurer(s) may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company with the information in its file.

Upon receipt from you, the Bureau will arrange disclosure of any information it may have in your file. Medical information will be disclosed only to your attending physician. If you question the accuracy of information in the Bureau's file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau's information office is MIB, Inc., P.O. Box 105, Essex Station, Boston, MA 02112; telephone number (617) 426-3660.

Hartford Life Insurance Company or its reinsurer(s) may also release information in your file to other insurance companies to which you may apply for life or health insurance, or to which a claim for benefits may be submitted.

Upon written request, Hartford Life Insurance Company will provide you with information in your file. Medical information will be disclosed only through a physician you designate. Details regarding your right to correct or amend information in your file will be furnished upon written request.

If you would like further details, contact Hartford Life Insurance Company, P.O. Box 2999, Hartford, CT 06104-2999, Attn: Special Risk Life-Health Department.

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