Complete all sections of the form accurately. Once completed, submit the form via mail to The Hartford, P.O. Box 14869, Lexington, KY 40512-4869, or via fax to 833-357-5153. Ensure all required fields are filled out to avoid delays in processing your claim.

There are no specific important dates for this form in 2024 and 2025. The form can be submitted as needed based on the individual's disability claim.

The purpose of this form is to collect necessary information from employees applying for long term disability income benefits. This includes personal details, information about the medical condition causing the disability, and details about healthcare providers and hospitals involved in the treatment. The form ensures that all relevant data is captured to process the claim efficiently and determine eligibility for benefits.

• 1. Last Name: The applicant's last name.
• 2. First Name: The applicant's first name.
• 3. Middle Initial: The applicant's middle initial.
• 4. Date of Birth: The applicant's date of birth.
• 5. Social Security Number: The applicant's social security number.
• 6. Address: The applicant's address (Street, City, State & Zip Code).
• 7. E-Mail Address: The applicant's email address for communication purposes.
• 8. Gender: The applicant's gender (Male, Female).
• 9. Personal Cell Telephone Number: The applicant's personal cell phone number.
• 10. Alternate Telephone Number: An alternate phone number for the applicant.
• 11. Authorization to Leave Confidential Information: Authorization to leave confidential medical and benefit information on the applicant's personal cell phone (Yes, No).
• 12. Marital Status: The applicant's marital status (Married, Single, Divorced, Widowed).
• 13. Employer: The applicant's employer name (include division, if applicable).
• 14. Occupation: The applicant's occupation.
• 15. Disability Information: Details about the applicant's disability, including onset date and if they had multiple employers.
• 16. Education: The applicant's formal education level and any licenses or certifications they hold.
• 17. Military Service: If the applicant has served in the military.
• 18. Past Work Experience: A description of the applicant's work experience over the past 20 years.
• 19. Rehabilitation Interest: If the applicant is interested in rehabilitation services.
• 20. Family Information: Information about the applicant's spouse and children.
• 21. Condition Causing Disability: Details about the condition causing the applicant's disability.
• 22. Healthcare Providers and Hospitals: List of healthcare providers and hospitals the applicant has visited for their condition.
• 23. Other Income: Information about other income benefits the applicant is receiving or eligible to receive.
• 24. Tax Withholding: Information about federal income tax withholding.
• 25. Date Signature: The applicant's signature and date.

If you fail to submit this form, your claim for long term disability benefits may be delayed or denied.

• Delayed Benefits: Without the completed form, the processing of your benefits will be delayed.
• Claim Denial: Failure to submit the form can result in a denial of your disability claim.

• 1. Disability Benefits Application: To apply for financial support due to long term disability.
• 2. Insurance Claims: To provide proof of disability to insurance companies.