Administered by:

Group Life and/or Accidental Death & Dismemberment Claim Forms for Employee or Dependent IMPORTANT INSTRUCTIONS FOR COMPLETING CLAIM FORM(s)

To the Employer and Employee/Beneficiary, as applicable: We know this is a difficult time and we want to assist you in filing your claim as quickly as possible. Please read these important instructions regarding completion of these forms. Also please read the “Important Notice” below. Part I – Employer’s Statement: (needed for Life or Accidental Death & Dismemberment claims) z Form is to be completed and signed by the Official Representative of the Employer. If this is a death claim, a certified Death Certificate must be attached to this form. z Submission of claims on any voluntary or contributory Life plans should include copies of the enrollment forms and proof of premium deductions at time of loss. All claims should be submitted with the beneficiary designation forms. Part II – Beneficiary Statement (needed for Life or Accidental Death claims) If more than one beneficiary, each beneficiary can either sign and date the one form, or complete separate forms - showing their date of birth and Social Security number

z

Part III – Claimant’s Statement (needed for Accidental Death or Dismemberment claims) Must be completed by claimant or beneficiary for any death or dismemberment due to an accident. z Additionally, please furnish any newspaper accounts, police or motor vehicle reports, and/or other pertinent information regarding the claimed accidental death or injury in order to facilitate consideration of such claim. z

Part IV – Attending Physician’s Statement (needed for Loss of Limb/Sight/Hearing/Speech claims) Attending Physician should complete pages 5 and 6 for above losses

z

Misc. – All Claims If the claim proceeds are payable to the Estate, Executors or Administrators of the Estate, Part 2 and/or 3 must be completed by an Executor or Administrator. A certificate of such person's legal appointment and qualification must be attached to this form. z If the beneficiary designate is a minor, Part 2 and/or 3 must be completed by a custodian or guardian. An official certificate of the guardian's legal appointment and qualification of the minor’s estate or property must be attached to this form, if applicable. z If claim is for a dependent child enrolled in an accredited school of higher learning, submitted documents should include a student enrollment verification form executed by the school. z

Release of claim forms is not an admission of coverage under a policy or for an employer, group or association. **IMPORTANT NOTICE** RESIDENTS OF ALL STATES EXCEPT AZ, CA, FL, NH & NJ: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or settlement 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 such person to criminal and civil penalties. AZ Residents: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CA Residents: For your protection California law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. FL Residents: Any person who 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 is guilty of a felony of the third degree. NH Residents: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NJ Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

GL-142675-B

Revised 4/03

1

Administered by:

Part I - Employer’s Statement

Underwriting Company (herein called the “Company”): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company

Group Life and/or Accidental Death & Dismemberment Claim Form for EMPLOYEE or DEPENDENT For Claims Assistance, Call 1- 800-303-9744

Name of Insured Employee/Participant

Date of Birth

Social Security Number

Name of Deceased or Injured (if different than above)

Date of Birth

Social Security Number

Employee Class #

Phone Number

Relationship to Employee Address

Location #

Amount of Employee’s Insurance Coverage

( ) Amount of Dependent’s Insurance Coverage:

Basic $__________

Basic $___________

Supplemental/Voluntary $ _________

Supplemental/Voluntary $_____________

AD&D $_______________(if applicable)

AD&D $_______________(if applicable)

Group Policy Nos.

Group Travel $______________ Is Employee Insurance In-Force? Yes No Effective Date:_____________________ Full-Time Employment Date of Retirement

Group Travel $________________ Is Dependent Insurance In-Force? Yes No Effective Date:_____________________ Annual Salary as defined in Policy

Life:

From:

$___________________(Attached W-2 if applicable)

AD&D:

Through:

Effective Date of Reported Salary:___________ Occupation of deceased/injured

Date of Death or Injury (Month/Day/Year)

Date Last Physically Reported for Work

Date of Termination

Has this employee requested No Is the current Beneficiary irrevocable? Yes conversion of this Group Are there any assignments attached to the policy? insurance to an Individual Policy? Yes No Full Name of Beneficiary(ies)

Address & Phone # (including area code)

Employer Representative Name (printed):

Yes

Date of Birth

No If so, explain:

Relationship to Insured

Employer Name/Address/Telephone/Fax:

Signature * The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to “Hartford Life Group Insurance Company”). GL-142675-B

Revised 4/03

Mail to: The Hartford Group Benefits PO Box 946790 Maitland, FL 32794-6790

2

Administered by:

Part II – Beneficiary’s Statement

Underwriting Company (herein called the “Company”): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company

FEDERAL LAW

Mail To:

The Hartford Group Benefits P. O. Box 946790 Maitland, FL 32794-6790

Federal Law requires us to give you this information. We may have to withhold and send to the IRS 31 % of certain reportable payments you may be entitled to. We will not have to withhold this amount if we have your correct Social Security Number, and you state that you have not been notified that you are subject to an IRS Back-up Withholding Order on Interest and Dividends.

NAME OF DECEASED:

Policy #(s) :

By signing below:

Claim # (if known):

(1) I Hereby Certify and Agree that I have not been notified by the Internal Revenue Service (IRS) that I am subject to a Back-up Withholding Order on Interest and Dividends. (If you have been so notified, cross out this statement "(1)". Provide your initials and today's date next to the cross out marks). (2) I Hereby Certify and Agree that I have read and understand the IMPORTANT NOTICE on page 2 of this claim form package. (3) I Understand and Agree that payment of the claim proceeds according to any alternate mode of settlement specified in the policy will only be made if the Company receives a written request for such alternate method of payment from me prior to the payment of the claim proceeds. (4) I Authorize the Company to pay the death proceeds into a Safe Haven Account (retained asset account). If a Safe Haven Account is not an available form of payment for the group referenced above, I authorize the Company to pay the proceeds to me in a lump sum payment. This will be in lieu of any alternate mode of settlement available under the policy. (If you do not wish to have the proceeds paid into a Safe Haven Account, you may cross out this statement "(4)", and attach your written request for some other method of payment available under the policy.) (5) I Authorize any physician, medical professional, hospital, covered entity as defined under HIPAA, insurer or other organization or person having any records, dates, or information concerning the deceased or injured's occupation, finances and health including protected health information, individually identifiable health information, summary health information, psychotherapy notes, mental health, HIV, and alcohol/drug records to release all such records in their entirety to the Company. I understand I may receive a copy of this authorization, and that this authorization is valid for the entire duration of this claim, and that I may revoke this authorization at any time by sending a request in writing to the Company. I understand that it may be necessary for the Company to provide such information or summaries thereof to the employer, regulatory state agency, or Workers' Compensation carrier.

Beneficiary Name (print)

Date of Birth:

Social Security Number

Date of Birth:

Social Security Number

Date of Birth:

Social Security Number

Date of Birth:

Social Security Number

X_________________________________________Date

For Assured Access purposes, sign as you would sign a check

Beneficiary Name (print) X_________________________________________Date

For Assured Access purposes, sign as you would sign a check

Beneficiary Name (print) X_________________________________________Date

For Assured Access purposes, sign as you would sign a check

Beneficiary Name (print) X_________________________________________Date

For Assured Access purposes, sign as you would sign a check * The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to “Hartford Life Group Insurance Company”).

GL-142675-B

Revised 4/03

3

Administered by:

Part III - Claimant’s Statement of Accidental Death or Injury

Underwriting Company (herein called the “Company”): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company

Mail To:

The Hartford Group Benefits, P. O. Box 946790, Maitland, FL 32794-6790

INSTRUCTIONS: Complete this form if you are applying for death or dismemberment benefits due to an Accident. If you have any questions regarding completion of this form, please contact the Claim Processing Center at 1-800-303-9744. Please use a separate sheet of paper where space does not permit GROUP POLICYHOLDER/EMPLOYER NAME: Name of Insured Employee/Participant Social Security # Policy Number(s) AD&D: Life: Name of Deceased or Injured (if different than above): Briefly describe occupational duties at the time of accident: Relationship to Employee: On what date did the accident happen? Yes Did the Accident result in death? Please describe all injuries received: Describe in detail how the accident happened:

Where did the accident happen? City______________State:____ No If Yes, on what date?_________________

Name and address of law enforcement agency involved: (Please submit copy of Police Accident Report an/or provide Case #): List name/address/phone # of all physicians consulted for this injury/death: List name/address/phone # of all hospitals consulted: Did the deceased/injured have any chronic disease or physical defect or deformity? Yes No If Yes, please describe in detail: Was an inquest held? Yes No Was autopsy performed? Yes No If yes, provide name/address: If Yes, attach a copy of verdict. Beneficiary Name: Address: Date Telephone: Your date of birth:

In what capacity are you making claim? (Note: If other than beneficiary, attach appropriate legal documents substantiating your authority.) Your address and telephone number if different than beneficiary: Your relationship to deceased or injured:

Your Social Security No.:

I AUTHORIZE the Company to release all of its collected health and financial information concerning me, including medical record information, to one or more The Hartford Affiliate for the purpose of evaluating my claim(s) for Life, Accident, or Disability Income benefits administered or insured by the The Hartford Affiliate. As used herein, “The Hartford Affiliate” means one of the The Hartford Affiliated insurance companies, including but not limited to, Continental Casualty Company, Continental Assurance Company, and CNA Group Life Assurance Company. I AUTHORIZE the Company and The Hartford Affiliate to provide a complete copy of my claim file and/or information concerning my health and finances, claim status, or summaries thereof, to my employer through the appropriate employee benefit/human resources coordinators for the purpose of processing my claim(s) or for the proper administration of the employer’s group benefit plan, including any disclosures which may be needed in order to facilitate my return to work with my employer. I further Authorize the Company to disclose any collected health or financial information, including medical record information, to my employer’s Workers’ Compensation carrier, in the event I file a Workers’ Compensation claim and such information is requested of the Company or The Hartford Affiliate. I UNDERSTAND that I may receive a copy of this authorization and that this authorization is valid for the entire duration of my claim. I UNDERSTAND that I may revoke this Authorization at any time by providing written notice to the Company, except to the extent that an individual has taken action in reliance upon such authorization prior to notice of the revocation. I AGREE that a photographic copy of this authorization shall be as valid as the original. Date Signature Of Person Completing This Form: * The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to “Hartford Life Group Insurance Company”).

GL-142675-B

Revised 4/03

4

Administered by:

Part IV - Attending Physician's Statement; Loss of Limb/Sight/ Hearing/Speech - - page 1

Underwriting Company (herein called the “Company”): * CNA Group Life Assurance Company Continental Assurance Company Continental Casualty Company

Please Print—Use A Separate Sheet of Paper Where Space Does Not Permit. Patient's Name

Date of Birth

Address

City

On what date did you first examine and treat the patient?

Where?

Had patient previously had medical attention? Yes No Describe the injury and it’s affected body part(s).

Social Security Number State

Zip Code

If Yes, by whom? Date of injury

What complications, if any, have arisen? What surgery was performed?

Date of surgery

Name of Surgeon Name and address of Hospital

From:

Was the injury described above, of itself, and independent of all other causes, sufficient to require amputation? Yes No

To: Did any disease process, other than the injury referred to, operate as a complication or contribute to the result in this case? Yes No If Yes, what? Was claimant under the influence of alcohol and/or drugs at the time of the accident or injury?

Yes

No

Please indicate location of amputation or area of injury, adding any necessary comment on chart provided.

Please indicate best corrected visual acuity and/or area of injury as of _____________________: (Date) Right Eye:____________________ Left Eye:_____________________ Is this loss of sight due to an injury irrecoverable? Yes _______ No _______

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Revised 4/03

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Part IV - page 2

In your medical opinion, has this patient sustained complete loss of hearing due to an injury? Yes

No

Right

Left

In your medical opinion, has this patient sustained complete and irrecoverable loss of speech due to an injury? Both Yes

No

Please provide copies of auditory test results. Please provide copies of speech test results.

Physician Name (print) Street Address

City/Town

Your Facsimile Number ( ) Physician’s Signature

Your Telephone Number ( ) Specialty/Degree

Please return completed form(s) to:

State/Providence

Zip Code

Taxpayer's Identification Number Date

The Hartford Group Benefits P. O. Box 946790 Maitland, FL 32794-6790

* The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life and Accident Insurance Company, Hartford Life Insurance Company and CNA Group Life Assurance Company (pending state approval of name change to “Hartford Life Group Insurance Company”).

GL-142675-B

Revised 4/03

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