(Not Valid for NY Residents)
DATE OF COVERAGE TERMINATION
(Enter as mm/dd/yyyy - i.e. 08/15/2007)
DATE OF BIRTH
(Enter as mm/dd/yyyy - i.e. 10/15/1977)
STATE OF RESIDENCE
(Enter resident state abbreviation - i.e. VA for Virginia)
AMOUNT OF LIFE INSURANCE REQUESTED
(Cannot exceed the individual's current amount) (Enter full amount i.e. 31000, not 31)
ESTIMATED ANNUAL COST Age on policy issue date:
The rates used to arrive at the cost above are those in effect as of January 1, 2007. The estimated annual cost provided above is an approximation only. The actual cost of conversion coverage will be the cost in effect as of the date of the application for conversion coverage. The actual cost will be shown on the Group Conversion Plan Life Insurance quote sheet sent to the applicant. The cost is based on information furnished on the Notice of Conversion Privilege form that the terminating individual sends to The Hartford.
A terminating individual may request a telephone quote estimate by calling Hartford Life's toll free telephone line at 1-877-320-0484, Monday through Friday, 9:00am - 5:00pm, EST. Terminating individuals residing in NY may also call this number for a quote.