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Hartford evidence of insurability form 2026

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The document is a Personal Health Application form from The Hartford, intended for employers and employees to apply for life insurance coverage. It includes sections for employer and employee details, coverage information, medical history questions, and certifications. Employers must complete specific sections before forwarding the form to employees, who are required to provide personal health information and authorize the release of medical records. The application must be submitted within 30 days of signing to avoid processing delays.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, which is pre-populated by your employer. Verify that the Employer Name, Policy Number, and contact details are correct.
In Section 2, enter the Employee Details. Fill in the Employee Name, Base Annual Earnings, Social Security Number, and Date of Hire clearly.
Proceed to Coverage Details. Check applicable boxes for current coverage and enter amounts for existing and additional coverage requested.
Complete Sections 3 through 6 with accurate personal information and medical history as required. Ensure all questions are answered fully to avoid delays.
Review Sections 7 through 10 for certifications and authorizations. Sign where indicated to confirm accuracy.
Once completed, save your form and submit it as instructed at the end of the document.

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