OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone...

16
Stock: 092779 Office of the Administrator P.O. Box 14464 Des Moines, IA 50306-8993 Dear FRA Member, The enclosed Enrollment Form confirms your eligibility status in connection to a valuable new benefit offer extended exclusively to a select group of FRA members. Called the FRA-endorsed V.I.P. Senior Term Life Insurance Plan, your newest member benefit opportunity is a senior group term life insurance benefit negotiated specifically for members ages 50-74. Please let me explain: At an age when many veterans report that adding additional life coverage often proves to be difficult, you can now easily add $15,000.00* ... $20,000.00* ... up to $25,000.00* ($5,000.00* or $10,000.00* for ages 65-74) in life insurance to your family’s financial protection. You don’t need a medical exam. You don’t need your doctor to send in your medical records. All it takes is a few answers on the enclosed Enrollment Form and we’ll get the paperwork going on as much as $25,000.00 (or $10,000.00 for ages 65-74) in FRA-endorsed V.I.P. Senior Term Life Insurance coverage. The FRA-endorsed V.I.P. Senior Term Life plan was carefully developed as an additional term life safety net for members like you (and your spouse if you’d like). No one else can activate this coverage. It’s a benefit offer reserved exclusively for selected FRA members – to thank you for your service to our country and your dedication to FRA. (Over for more details on your revised FRA-endorsed member benefit status) >>> 1 (Continued...)

Transcript of OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone...

Page 1: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 092779

Office of the AdministratorP.O. Box 14464

Des Moines, IA 50306-8993

Dear FRA Member,

The enclosed Enrollment Form confirms your eligibility status in connection to a valuable new benefitoffer extended exclusively to a select group of FRA members.

Called the FRA-endorsed V.I.P. Senior Term Life Insurance Plan, your newest member benefitopportunity is a senior group term life insurance benefit negotiated specifically for members ages50-74.

Please let me explain:

At an age when many veterans report that adding additional life coverage often proves to bedifficult, you can now easily add $15,000.00* ... $20,000.00* ... up to $25,000.00* ($5,000.00* or$10,000.00* for ages 65-74) in life insurance to your family’s financial protection.

You don’t need a medical exam. You don’t need your doctor to send in your medical records.

All it takes is a few answers on the enclosed Enrollment Form and we’ll get the paperwork going onas much as $25,000.00 (or $10,000.00 for ages 65-74) in FRA-endorsed V.I.P. Senior Term Life Insurancecoverage.

The FRA-endorsed V.I.P. Senior Term Life plan was carefully developed as an additional term life safetynet for members like you (and your spouse if you’d like).

No one else can activate this coverage.

It’s a benefit offer reserved exclusively for selected FRA members – to thank you for your serviceto our country and your dedication to FRA.

(Over for more details on your revised FRA-endorsed member benefit status) >>>

1(Continued...)

Page 2: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

ADDITIONAL MONEY FOR YOUR LOVED ONES ... JUST WHEN OTHER BENEFITSTOO OFTEN FADE AWAY

When an FRA member switches jobs or retires the employer-sponsored life coverage stops, ordrastically reduces as we get older.

Regardless of the reason, the end result can be the same:

Not enough money to help pay off a mortgage or big medical bills. Not enough money to take careof final expenses or funeral costs.

Not enough to make ends meet as families struggle to put their lives back together.

But today you can enroll for additional life insurance ranging from $5,000.00 to $25,000.00,depending on your age.

Sent straight to your family just when they may need it most.

Your FRA-endorsed V.I.P. Senior Term Life coverage kicks in – with a benefit – starting on day 1 forcovered accidents and injuries.

You’ll have coverage for – accidents, injuries and illnesses – after 2 years.

Just take advantage of your member’s opportunity to request your new V.I.P. Senior Term LifeInsurance coverage right away.

GUARANTEED ACCEPTANCE MEANS YOU CANNOT BE TURNED DOWN

Your status as a guaranteed acceptance FRA member makes you eligible for simplified enrollmentprivileges when you request V.I.P. Senior Term Life coverage.

There are no physicals involved. No medical exam required. You don’t even have to be activelyat work.

As an FRA member age 50 or over, everything you need is included right here in this benefitdocumentation packet.

Just complete the enclosed Enrollment Form and sign where indicated.

You don’t even send money today.

SURVIVING SPOUSE CONTINUATION OF COVERAGE

And what about protection for your spouse if you die while your spouse is covered under thePolicy?

Your spouse may continue his or her coverage as long as we receive the spouse’s request andrequired premium to continue the coverage within 31 days of the premium due date next following themember’s death.

(over, please)2

Page 3: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

ECONOMICAL GROUP RATESTake a 54-year-old member, for example.70¢ a day sets up $25,000.00 of coverage.

And you can even add your spouse. All it takes is 70¢ more a day to add a 54-year-old spouse for$25,000.00 of V.I.P. Senior Term Life benefits.

100% SATISFACTION GUARANTEE

Of course, there’s no obligation when you request your FRA-endorsed V.I.P. Senior Term Lifecoverage.

Just mail back your completed Enrollment Form to get the paperwork started on your V.I.P.Senior Term Life Insurance coverage.

We’ll mail your official Certificate of Insurance as soon as coverage is approved.

Look it over for 30 days. You don’t pay a penny until you’re fully satisfied. If V.I.P. Senior Term Life isn’twhat you had in mind, just let us know during that time. You’ll get a 100% refund of any money you may havesent, minus any claims paid.

No hassles and no questions asked.

But it’s important to act on this member benefit offer right away.

Guaranteed acceptance (and your “no-medical-exam” enrollment opportunity) cannot be extendedindefinitely.

That’s why I must urge you to mail your completed Enrollment Form within the next 10 days.

Sincerely,

Anthony A. Baldus, PrincipalMercer Health & Benefits Administration LLC FRA-endorsed Insurance Programs Administrator License #8704140

P.S. Your guaranteed acceptance status now makes you eligible to request V.I.P. Senior Term Lifecoverage – with NO extra paperwork required.

*At age 80, coverage, if greater than $5,000, will reduce to $5,000 with an appropriate adjustment in premium.

Please refer to the brochure for more information including costs, exclusions, limitations, reduction of benefitsand terms of coverage.

GRADED DEATH BENEFIT: During the first two years of coverage the benefit payable for death due tosickness will be the premiums paid plus interest.

Master Policy #AGL-1906

Copyright 2020 Mercer LLC. All rights reserved. 3 FRASRL

Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

Page 4: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

THIS PAGE IS INTENTIONALLY LEFT BLANK.

Page 5: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Name:Last First MI

Add 1:

Add 2:

City, St., Zip:

Stock: 908786

AGL-190609842-Q

074030010144

Senior Term Life Insurance PlanEnrollment FormFRA-endorsed V.I.P.Senior Term Life Plan

To Enroll:Send this completed form to:

ADMINISTRATORFRA-ENDORSED INSURANCE PROGRAMSP.O. Box 14464Des Moines, IA 50306-8993

[email protected]

Underwritten by:

Hartford Life and Accident Insurance CompanyHartford, CT 06155

1. Please verify information and complete as necessary.Member's Date of Birth Spouse's Name

(Mo./Day/Yr.)Member No. Spouse's Date of Birth

(Mo./Day/Yr.)Member's Social Security No. Sex: q M q F

Sex: q M q F

Home Phone

E-Mail Address(Optional. For internal use only.)

2. Please check which FRA-ENDORSED V.I.P. Senior Term Life benefits you’d like.FRA MemberAge Coverage50-64 q $5,000 (00C1) q $10,000 (00E1) q $15,000 (00F1) q $20,000 (00G1) q $25,000 (00H1)65-74 q $5,000 (Y0C1) q $10,000 (Y0E1)

FRA SpouseAge Coverage50-64 q $5,000 (00C5) q $10,000 (00E5) q $15,000 (00F5) q $20,000 (00G5) q $25,000 (00H5)65-74 q $5,000 (Y0C5) q $10,000 (Y0E5)

Member SpouseBy applying for insurance, do you intend to replace, discontinue or change an existing policy of life Yes No Yes Noinsurance?......................................................................................................................................... q q q q

BENEFICIARY DESIGNATION: Your FRA-endorsed V.I.P. Senior Term Life benefits will be paid to your spouse,children, parents or estate (in that order). The Member is the beneficiary for Spouse Coverage. If you’d like todesignate a different beneficiary, please complete below.

(Beneficiary Name) (Address) (SSN) (Relationship) D.O.B %

Form PA-9349 (1906) (HLA) 1 (Over, please)

Page 6: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

3. Please read, sign and date.NOTIFICATION: I/We hereby enroll with Hartford Life and Accident Insurance Company for coverage under theFRA-endorsed V.I.P. Senior Term Life Insurance Plan. I/We certify that I am/we are under age 75 and the abovestatements are full, complete and true for each person to be insured, to the best of my/our knowledge and belief.

I/We understand that coverage will become effective after receipt of the first payment of premium. I/We alsounderstand that during the first two policy years, the death benefit payable will be an amount equal to the premiumspaid for coverage, with interest, using an annual interest rate of at least The Company’s corporate interest rate, if deathresults from causes other than injury. The full benefit amount is payable if death results from an accident. After twoyears, the death benefit will be the full benefit amount. At age 80, coverage reduces to $5,000.00.

In the event of any discrepancy between this document and the policy, the terms of the policy apply. Completecoverage information is in the certificate issued to each insured individual.

X XFRA Member’s Signature Date

X XSpouse’s Signature (if applying for coverage) Date

GROUP TERM LIFE INSURANCE CERTIFICATE WITH GRADED DEATH BENEFIT.

SEND NO MONEY NOW.Please mail your FRA-endorsed V.I.P. Senior Term Life Enrollment Form within the next 10 days.

FRA-endorsedInsurance Administrator

P.O. Box 14464Des Moines, Iowa 50306-8993

www.frainsure.com

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing company of HartfordLife and Accident Insurance Company.

Copyright 2020 Mercer LLC. All rights reserved. 2

Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

FRASRE

Page 7: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

Page 8: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

THIS PAGE IS INTENTIONALLY LEFT BLANK.

Stock: 660005

Page 9: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

Page 10: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.
Page 11: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

AUTOMATIC CHECK WITHDRAWAL REQUEST: By selecting Automatic Check Withdrawal, your premium willautomatically be withdrawn from your checking account. Please provide the information requested below.

Routing #: ____ ____ ____ ____ ____ ____ ____ ____ ____ Account #:_________________________________

I request that you pay and charge my account debits drawn from my account by the Plan Administrator to its order. Thisauthorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fullyprotected in honoring any such debits. I also agree that you may, at any time, end this agreement by giving 30 daysadvanced written notice to me and to the Plan Administrator. You are to treat such debit as if it were signed by me. If youdishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance.

Signature of Premium Payer______________________________________________ Date_____________________

Stock: 660005

Page 12: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

THIS PAGE IS INTENTIONALLY LEFT BLANK.

Stock: 660005

Page 13: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 908786

FRA-ENDORSED V.I.P. SENIOR TERMLIFE INSURANCE PLAN

A good value comes down to what you get for what you pay.This V.I.P. Senior Term Life Insurance Plan is designed to be an economical value, offered to FRA members in

recognition of their service record and good standing within the association.

What you get:ü A choice of benefit amounts to suit your specific needsü The opportunity to bring your current coverage up to dateü Important coverage that helps pay final expenses, including funeral costs, mortgage payoff and outstanding

debtü Easy enrollment, with no medical exam required

üWhat you pay:Economical member-only rates negotiated on your behalf.The V.I.P. Senior Term Life Insurance Plan is offered for the exclusive benefit of eligible FRA members. For thisreason, we are able to make it available to members in good standing at economical group rates. The chart belowshows the rate for the benefit amount you select, based on your age.

FRA-endorsed V.I.P. Senior Term Life Insurance PlanMONTHLY GROUP RATES

Attained Age–Member & Spouse

$25,000.00** $20,000.00** $15,000.00** $10,000.00** $5,000.00**

50-54 $21.44 $17.15 $12.86 $8.58 $4.2955-59 $32.50 $26.00 $19.50 $13.00 $6.5060-64 $50.79 $40.63 $30.48 $20.32 $10.1665-69 $82.60* $66.08* $49.56* $33.04 $16.5270-74 $131.13* $104.90* $78.68* $52.45 $26.2375-79 $209.77* $167.82* $125.86* $83.91* $41.9580-84 – – – – $69.28*85-89 – – – – $120.87*

*Renewalpremiums only

** At age 80, coverage, if greater than $5,000, will reduce to $5,000 with an appropriate adjustment in premium.

You will be billed four times a year. If applicable, anadditional $2 billing fee will be included on yourbilling notice payable to the administrator. To savethe fee, select Electronic Funds Transfer (EFT) as asafe and secure payment option. Rates and/or benefitsmay be changed on a class basis. Rates are based on theattained age of the Insured Person and increase as youenter each new age category. Coverage begins on thefirst day of the month following approval by the Insurerand payment of the first premium. Coverage continueswith no decrease in coverage until you reach age 80. Atage 80, coverage, if greater than $5,000, will reduce to$5,000 with an appropriate adjustment in 1

premium. Coverage cannot be canceled as long as youremain a member of the Fleet Reserve Association, payyour premiums on time and the Master Policy remains inforce. Coverage for your spouse will continue for as longas he/she remains eligible due to age and marital status.Full details are contained in the Certificate of Insurance,which will be issued to persons who become insured underthe Plan. The Plan may not be available to residents of allstates. This Plan terminates at age 90.

(Next page, please)

Page 14: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

LimitationsIf you or your dependent die while covered under thePolicy, we will pay the deceased person’s life insurancebenefit after we receive Proof of Loss, in accordance withthe Proof of Loss provision and: 1) if death is the result ofan Injury and occurs during the first 2 years of coverageunder the policy, we will pay the deceased person’sAmount of Life Insurance; 2) if death is the result ofsickness and occurs during the first 2 years of coverageunder the Policy, the amount payable will be an amountequal to the premiums paid for coverage, with interest,using an annual interest rate of at least the company’scorporate interest rate; or 3) if death is the result of anInjury or Sickness and occurs after 2 years of coverageunder the Policy, we will pay the deceased person’samount of life insurance.

EligibilityAs an active FRA member, between the ages of 50 and74, and a resident of the U.S., you and your Spouse areeligible for coverage. Your Spouse may not be legallyseparated or divorced from you.

This coverage is available only for residents of the UnitedStates excluding AR, FL, IA, ID, LA, MD, ME, MT, OR,TX, UT and WA.

Effective DateYour coverage will become effective upon receipt of theEnrollment Form and your first premium payment.

GRADED DEATH BENEFIT: During a person’s first twoyears of coverage, benefits for loss of life due to Injury arecovered. Loss of life due to sickness is not covered duringthe first two years. In the case of loss of life for sickness,premiums plus interest will be refunded. Since coverage isissued without medical underwriting, the premium ratebeing charged includes an extra mortality risk charge.

TerminationCoverage will end on the earliest to occur of: the date theMaster Policy terminates; or the Premium Due Date on ornext following the date You: a) cease to be an activemember of FRA; b) attain age 90; the date You are nolonger in a class eligible for coverage, or the class iscanceled; or the Premium Due Date that You fail to payany required premium, subject to the Individual GracePeriod. Your dependent’s coverage will remain in effect aslong as your coverage is active, premiums are paid, andthey meet the eligibility requirements.

ExclusionsIf a Covered Person commits suicide, while sane orinsane, during his or her first two years of coverage underthe policy, we will only pay an amount equal to thepremium paid for coverage to the date of death. The lifeinsurance benefit is payable if a covered person is insuredunder the policy and commits suicide after the two-yearperiod.

The two-year suicide exclusion, stated above, will alsoapply if a covered person commits suicide during the twoyears immediately following an increase in coverage.

2

In that event, the amount of insurance payable will equal theamount of insurance in force prior to the increase plus anamount equal to the premium paid for the increase to thedate of death.

Accelerated Death BenefitIf a Covered Person:a) is under age 80;b) is covered for a term life insurance benefit amount underthe policy of at least $5,000;c) is diagnosed as Terminally Ill while covered under thepolicy, with a life expectancy of 12 months or less, andgives us satisfactory proof of such terminal illness; andd) requests in writing a portion of the amount of his or herlife insurance benefit be paid as an accelerated benefit; wewill pay an Accelerated Death Benefit up to 50% (maximum$12,500.00) of the Covered Person’s Life Insurance Benefit.

Upon satisfactory proof of the Covered Person’s TerminalIllness, we will also:a) continue his or her life insurance; andb) waive premiums for such insurance.

However, continued insurance will be subject to anyreductions in amounts of insurance provision under thepolicy. Termination of the policy will not affect suchcontinuation.

The Covered Person’s Amount of Life Insurance payableupon his or her death will be reduced by any AcceleratedBenefit Amount already received under this benefit. Receiptof accelerated benefits may be taxable. Seek assistancefrom your personal tax advisor for more information1.1This information is written in connection with the promotionor marketing of the matter(s) addressed in this material. Theinformation cannot be used or relied upon for the purpose ofavoiding IRS penalties. These materials are not intended toprovide tax, accounting or legal advice. As with all mattersof a tax or legal nature, you should consult your own tax orlegal counsel for advice.

Important DefinitionsInjury means bodily injury resulting directly from anaccident, and independently of all other causes, whichoccurs while covered under the policy. Loss resulting fromsickness or disease, except a pus-forming infection whichoccurs through an accidental wound, or medical or surgicaltreatment of a sickness or disease, is not considered asresulting from Injury.

Conversion ProvisionIf a Covered Person ceases to be insured under the policyfor any reason except nonpayment of premium, he or shemay have the right to convert the coverage that terminatedto an individual conversion policy without providingevidence of insurability. Conversion is not available for anyamount of life insurance for which the Covered Person wasnot eligible or covered under the policy or for any amount oflife insurance which was, or is being, continued inaccordance with any Waiver of Premium provision.

(Next page, please)

Page 15: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

Stock: 660005

If coverage under the policy ends because the policyterminated or coverage for an eligible class of persons isterminated, the Covered Person must have been insuredunder the policy five years or more in order to be eligible toconvert coverage. The amount which may be convertedunder these circumstances is limited to the lesser of:

a) $10,000; or

b) the life insurance benefit under the policy less anyamount of life insurance for which the covered maybecome eligible under any group life insurance policyissued or reinstated within 31 days of termination of grouplife coverage.

If coverage under the policy ends for any other reason,except nonpayment of premium, the full amount ofcoverage which ended may be converted.

Insurer, as used on this provision, means us or anotherinsurance company which has agreed to issue conversionpolicies according to this conversion privilege.

To convert coverage, the Covered Person must complete aNotice of Conversion Right form and return it to the Insurerwithin 31 days after he or she ceases to be covered underthe policy. After the Insurer verifies eligibility for conversioncoverage, they will send the Covered Person a conversionpolicy Proposal. The Covered Person must:a) complete and return the request form in the proposal; andb) pay the required premium for coverage; within the time

period specified in the proposal.

Any individual policy issued to under the conversionprovision will be effective as of the 32nd day after the datecoverage ends, and will be in lieu of coverage for thisamount under the policy.

The conversion policy will:a) be issued on one of the Life Insurance policy forms theInsurer is issuing for this purpose at the time of conversion;andb) base premiums on the Insurer’s rates in effect for newapplicants of the Covered Person’s class and age at thetime of conversion.

The conversion policy will not provide:a) the same terms and conditions of coverage as the policy;b) any benefit other than a life insurance benefit; andc) term insurance.

If a Covered Person dies before coverage is converted, andhis or her death occurs within 31days of the date coverageunder the policy terminates, we will pay the deceasedperson’s amount of life insurance he or she would have hadthe right to apply for under this provision.

If the conversion policy has already taken effect, no lifeinsurance benefit will be payable under the policy.

If a Covered Person is approved for Waiver of Premiumafter a conversion policy has been issued, any benefitpayable at the Covered Person’s death under the policy willbe paid only if the conversion policy is surrendered.

3

This brochure explains the general purpose of theinsurance described, but in no way changes or affects thepolicy as actually issued. In the event of a discrepancybetween this brochure and the policy, the terms of thepolicy apply. All benefits are subject to the terms andconditions of the policy. Policies underwritten by HartfordLife and Accident Insurance Company detail exclusions,limitations, reduction of benefits and terms under whichthe policies may be continued in full or discontinued.Complete details are in the Certificate of Insurance issued toeach insured individual and the Master Policy issued to thepolicyholder.This is private insurance. This insurance is not associatedwith SGLI.

Administered by:

Mercer Consumer,a service of Mercer Health & Benefits Administration LLCP.O. Box 14464Des Moines, IA 50306-8993

[email protected]

AR Insurance License #100102691CA Insurance License #0G39709In CA d/b/a Mercer Health & Benefits InsuranceServices LLC

Underwritten by:

Hartford Life and Accident Insurance CompanyHartford, CT 06155

The Hartford® is The Hartford Financial Services Group,Inc. and its subsidiaries, including issuing company ofHartford Life and Accident Insurance Company.

FRASRP

Copyright 2020 Mercer LLC. All rights reserved.

Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

Page 16: OfficeoftheAdministrator P.O.Box14464 DesMoines,IA50306-8993€¦ · Sex:qM qF HomePhone E-MailAddress (Optional.Forinternaluseonly.) 2.PleasecheckwhichFRA-ENDORSEDV.I.P.SeniorTermLifebenefitsyou™dlike.

THIS PAGE IS INTENTIONALLY LEFT BLANK.

Stock: 660005