Group Life Application
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.
 
Life Insurance Application Acrobat PDF
 
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2. Mail your completed application to:
Hagan Benefits, Inc.
Attn: ACEP
P.O. Box 5090
Sioux Falls, SD 57117-5090
 
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. If you have any questions, please feel free to call Hagan Benefits at number: 1-800-456-0737
 
Disability Application
Take the first step towards protecting yourself from the potential loss of income as a result of a disability by completing the application today.
 
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.
 
Disability Income Application Acrobat PDF
 
If you don't have Adobe Acrobat Reader click the icon below to download for free.

 
2. Calculate the appropriate amount of monthly benefit and the corresponding premium on the enclosed worksheet.
 
3. Mail your completed application to:
Hagan Benefits, Inc.
Attn: ACEP
P.O. Box 5090
Sioux Falls, SD 57117-5090
 
PLEASE SEND NO MONEY NOW; YOU WILL BE BILLED AFTER YOUR APPLICATION IS APPROVED.
When your Application is approved, you will receive your Certificate of Insurance. You will then have 30 days to review the Plan and to decide if the coverage is right for you.
 
Acceptance into this plan is subject to medical evidence of insurability as determined by Hartford Life. 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 feel free to contact the plan administrator, Hagan Benefits, Inc., if you have any questions regarding this plan or how to complete your application. Their toll-free number is: 1-800-456-0737.
 
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.
 
Hartford Life is the 3rd largest life insurance group in the U.S. based on assets and the fastest growing major life insurance organization of the dedade.** Our investment portfolio is of the highest quality, and our superior financial returns continue to earn strong stable ratings in the industry.
 
** Based on year-end statutory asset data form Townsend & Schupp, 1999
 
Plan Administered by:
Hagan Benefits, Inc.
Po Box 5090
Sioux Falls, SD 57117-5090
 
Underwritten by: Hartford Life Insurance Company
Hartford, Connecticut 06115
 
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