use green claim form db-300 if you become sick or disabled after having been unemployed more than four (4) weeks. Signature. including The Hartford defined as “Benefits Manager(s)”) I understand that My Information disclosed to Benefits Managers pertaining to certain alcohol or drug abuse treatment or HIV/AIDS or other communicable or sexually-transmitted disease is protected by federal (42 CFR Part 2) and state Name of person completing this form (if this claim is approved for disability benefits, the benefit check will be sent to the employee with a copy to you). LC-76 ADA Medical Assessment Form I i Forms can be mailed to: Hartford Leave Management P.O Box 14285 Lexington, KY 40512-4285 Or faxed to: Toll Free Fax Number: (877) 588-4817 The Hartford P.O. Date. 08/2016 If you need to file an auto insurance claim, homeowners insurance claim, employee benefits claim, or business insurance claim, this is the page you need. (Please print or type) Title. LC-7137-11. The Hartford also provides administrative and claim services for employer leave of absence programs and self-funded disability benefit plans. The Hartford also provides administrative and claim services for employer leave of absence programs and self-funded disability benefit plans. HARTFORD LIFE INSURANCE COMPANY HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS LC-4571-34 (Printed in U.S.A.) Page 1 of 10 01/2013 Section I Employer's Statement - … Here's a listing of important claims contact phone numbers and links for The Hartford. It shall not be considered legal advice. claimant: read the following instructions carefully notice and proof of claim for disability benefits the hartford db-450 (11-98) health care provider … This informational material is subject to change as The Hartford continues to receive guidance from states and municipalities. LC-4571-47. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. The Hartford is the administrator for certain group benefits business written by Aetna Life Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). BOX 14869 LEXINGTON, KY 40512 PHONE: (800) 205-7651 FAX: (833) 357-5153 NOTICE OF DISABILITY FORM – Supplemental Sickness Benefit Plan THE HARTFORD is the claim administrator for your Railroad Supplemental Sickness Benefit Plan Within 60 days of your first day absent from work call 1800-205-7651 or complete Disability Form Series includes GBD-1000, GBD-1200, or state equivalent. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries. The Hartford also provides administrative and claim services for employer leave of absence programs and self-funded disability benefit plans. LC-7135- 10 Printed in U.S.A Page 1 of 2. Please verify if the employee qualifies for any other group benefits through The Hartford and submit the claim accordingly. Page 1 of 2. The Hartford is the administrator for certain group benefits business written by Aetna Life Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). The Hartford is the administrator for certain group benefits business written by Aetna Life Insurance Company and Talcott Resolution Life Insurance Company (formerly known as Hartford Life Insurance Company). 08/2016 The Hartford® is underwriting companies Hartford Life and Accident Insurance Company and Hartford Life Insurance Company. The Hartford® is underwriting companies Hartford Life and Accident Insurance Company and Hartford Life Insurance Company.

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