CERTIFICATE OF INSURANCE HARTFORD LIFE AND ... - Imala.com 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing the Employer Group Information section at the top of Page 1. Ensure you provide the full name of your business, address, and plan number.
3. In Section A, indicate whether you are enrolling or making changes by checking the appropriate boxes. Fill in effective dates and reasons for changes where required.
4. Proceed to Section B to enter your personal information, including your Social Security Number, name, and contact details. Ensure all fields are filled accurately.
5. In Section D, list individuals for whom you are enrolling or changing coverage. Use the designated codes (A for add, C for change, R for remove) next to each name.
6. Finally, review all sections for accuracy before signing in the designated area on Page 3. Your signature is essential for processing.

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