Get To View Hartford Notice Of Continuation Of Coverage - Lsu Hospitals - Lsuhospitals

This guide provides clear and concise instructions for completing the To View Hartford Notice Of Continuation Of Coverage form, designed for users losing coverage under their employer's group plans. Follow these steps to ensure accurate submission and to explore your continuation coverage options.

Follow the steps to fill out the form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred PDF editor.
2. Begin by filling out the required employer information, including the employer's name and policy number.
3. In the section for employee information, enter your name, employee ID, and the date of completion.
4. Provide your last day worked or the date you are no longer in an eligible class, followed by the date of group coverage termination.
5. State the reason for termination in the specified field.
6. An employer representative must sign and print their name, provide an email address, and a telephone number for contact.
7. Indicate your interest in receiving a Life Conversion quote or a Portability enrollment form by checking the corresponding box.
8. Fill in your personal details, including your name, date of birth, the last four digits of your Social Security number, your address, city, state, and zip code.
9. Include your telephone number and email address for follow-up communication.
10. If applicable, provide information for any dependents by listing their names, relationships, and dates of birth.
11. Read and acknowledge the time limits for submitting the form by signing and dating the form in the designated area.
12. Once completed, save your changes, and then print, download, or share the form as needed.

Start filling out your documents online to ensure your coverage continues!