NASW ASI Long Term Disability Insurance Plan
How would you or your family make ends meet if a disability kept you from working?
Long Term Disability Insurance Plan
The NASW ASI Long Term Disability Insurance Plan helps protect you and your spouse/domestic partner with monthly disability benefits of up to $6,000.
Most things in your life depend on your ability to earn an income. Your home. Your everyday living expenses. Your children’s care and educational needs. Your savings. Your hopes for retirement. Your dreams for the future.
So, if your or your spouse/domestic partner’s income stops due to a disabling Injury or Sickness, how will you pay your mortgage, your household bills, and the everyday living expenses for you and your family? Will you have to dip into your savings or other assets? And will your savings, the equity in your home, your retirement nest egg, and your other assets be able to carry you through until you’re recovered and able to return to work? And, would you even want to use up your current financial resources like that, anyway?
With so many things in life being uncertain, why not help protect yourself and your loved ones from the financial risks and uncertainties surrounding a Disability? Secure NASW ASI Disability Insurance Plan today … to help protect you if you are Totally Disabled due to a covered Sickness or Injury.
This program offers three affordable coverage plan options to help fit your needs and budget.
If Totally Disabled due to a covered Sickness or Injury, you and your spouse/domestic partner’s can receive monthly benefits from $100 up to $6,000, depending on which option you select and your pre-disability earnings.
Plus, you and your spouse/domestic partner pay an affordable, group rate thanks to NASW’s group purchasing power.
For more information, call toll-free (866) 591-8267.
Disability Form Series includes GBD-1000, GBD-1200, or state equivalent
70571
Underwritten by: Hartford Life and Accident Insurance Company
Hartford, CT 06155
(AGP-5883 and AGP-5884)
May not be available in all states.
Choose Among Three COVERAGE OPTIONS
Basic Plan:
- Monthly Benefit Amounts Available: From $100 up to $1,200.
- Elimination Period Before Benefits Begin: 28 consecutive days of Total Disability.
- Benefit Period: For Total Disability caused by an Injury: prior to age 63 benefits continue up to the earlier of 5 years or to age 65; age 63 to age 69 benefits continue to the earlier of 2 years or to age 70.
- For Total Disability caused by Sickness, benefits continue to the earlier of 2 years or to age 70. (Disability benefits are not available after age 70 for Disability caused by Sickness or Injury.)
Extended Plan: Longer Benefit Periods
- Monthly Benefit Amounts Available: From $100 up to $1,200.
- Elimination Period Before Benefits Begin: 28 consecutive days of Total Disability.
- Benefit Period: For Total Disability caused by an Injury: prior to age 63 benefits continue to age 65; age 63 to age 69 benefits continue up to the earlier of 2 years or to age 70.
- For Total Disability caused by Sickness, benefits continue up to the earlier of 5 years or to age 70.
Select Plan: Highest Monthly Benefit Amounts Available
- Monthly Benefit Amounts Available: From $100 up to $6,000.
- Elimination Period Before Benefits Begin: 90 consecutive days of Total Disability.
- Benefit Period: For Total Disability caused by an Injury: prior to age 63 benefits continue to age 65; age 63 to age 69 benefits continue up to the earlier of 2 years or to age 70.
- For Total Disability caused by Sickness, benefits continue up to the earlier of 5 years or to age 70.
Replaces up to 75% of Your Pre-disability EARNINGS
You are eligible as long as you are under age 65, Actively at Work at least 30 hours per week, and a a resident of the United States. Your spouse/domestic partner is eligible as long as he/she is under age 65, is not legally separated or divorced from you, is Actively at work at least 30 hours per week, has been working full-time for at least 30 days before his/her effective date, and is a resident of the United States. When both spouses are eligible, each may apply; however, coverage may not be duplicated by applying as dependents of the other.
Offset Provision: The benefit amount payable as a result of the insured person’s Total Disability will be the lesser of the Monthly Benefit or 75% of your Pre-Disability Earnings minus any Other Income Benefits, such as social security or retirement disability benefits, including those for which the insured person could collect but did not apply, and all other income from any employer or other work. In no event will the Monthly Benefit elected exceed 75% of the insured person’s Pre-disability Earnings.
However, if you or your spouse’s Monthly Benefit payable would reduce to less than 15% of the Monthly Benefit due to Other Income Benefits, then the minimum Monthly Benefit under the Policy will be 15% of you or your spouse’s Monthly Benefit.
This example is for purposes of illustrating the effect of the benefit reductions and is not intended to reflect the situation of a particular claimant under the Policy:
Insured’s monthly Pre-Disability Earnings | $3,000 |
Disability benefits percentage | x 75% |
Unreduced maximum benefit | $2,250 |
Less any Social Security Disability benefit per month | – $ 1,100 |
Less any State Disability benefit per month | – $ 500 |
Total amount of Disability benefit per month | $ 650 |
Pays Benefits for all Covered Total Disabilities
This plan will pay you the Monthly Benefit you select (up to 75% of your Pre-Disability Earnings) if you become Totally Disabled due to a covered Injury or Sickness.
Includes a Rehabilitative Employment Benefit
You or your spouse can even collect partial Monthly Benefits while getting back to work under your and your spouse’s plan Rehabilitative Employment Benefit. If, while you or your spouse are Totally Disabled, you and your spouse are able to and choose to return to work, you or your spouse will continue to receive a Monthly Benefit equal to your or your spouse’s Total Disability Monthly Benefit, less 50% of any income you or your spouse receive. The sum of the Monthly Benefit and total income received from Rehabilitative Employment may not exceed 100% of yours or your spouse’s Pre-Disability Earnings. If it does, the Monthly Benefit will be reduced by the excess amount.
Apply Today
Simply download, complete, sign and return/upload the application. Send no money now.
Application is subject to approval by Hartford Life and Accident Insurance Company.
Once approved, you will be billed on a quarterly basis.
Questions?
Call toll-free (866) 514-8974.
Disability Form Series includes GBD-1000, GBD-1200, or state equivalent
70571
Underwritten by: Hartford Life and Accident Insurance Company
Hartford, CT 06155
(AGP-5883 and AGP-5884)
May not be available in all states.
Basic Plan – Monthly Rates
Monthly Benefit | Age Range | |||||
---|---|---|---|---|---|---|
18 – 29 | 30 – 39 | 40 – 49 | 50 – 59 | 60 – 64 | 65 – 69* | |
$1,200 | $14.28 | $17.52 | $21.36 | $31.32 | $45.84 | $52.36 |
$1,150 | 13.68 | 16.79 | 20.47 | 30.01 | 43.93 | 50.18 |
$1,100 | 13.09 | 16.06 | 19.58 | 28.71 | 42.02 | 48.00 |
$1,050 | 12.49 | 15.33 | 18.69 | 27.40 | 40.11 | 45.81 |
$1,000 | 11.90 | 14.60 | 17.80 | 26.10 | 38.20 | 43.63 |
$950 | 11.30 | 13.87 | 16.91 | 24.79 | 36.29 | 41.45 |
$900 | 10.71 | 13.14 | 16.02 | 23.49 | 34.38 | 39.27 |
$850 | 10.11 | 12.41 | 15.13 | 22.18 | 32.47 | 37.09 |
$800 | 9.52 | 11.68 | 14.24 | 20.88 | 30.56 | 39.41 |
$750 | 8.92 | 10.95 | 13.35 | 19.57 | 28.65 | 32.72 |
$700 | 8.33 | 10.22 | 12.46 | 18.27 | 26.74 | 30.54 |
$650 | 7.73 | 9.49 | 11.57 | 16.96 | 24.83 | 28.36 |
$600 | 7.14 | 8.76 | 10.68 | 15.66 | 22.92 | 26.18 |
$550 | 6.54 | 8.03 | 9.79 | 14.35 | 21.01 | 24.00 |
$500 | 5.95 | 7.30 | 8.90 | 13.05 | 19.10 | 21.82 |
$450 | 5.35 | 6.57 | 8.01 | 11.74 | 17.19 | 19.63 |
$400 | 4.76 | 5.84 | 7.12 | 10.44 | 15.28 | 17.45 |
$350 | 4.16 | 5.11 | 6.23 | 9.13 | 13.37 | 15.27 |
$300 | 3.57 | 4.38 | 5.34 | 7.83 | 11.46 | 13.09 |
$250 | 2.97 | 3.65 | 4.45 | 6.52 | 9.55 | 10.91 |
$200 | 2.38 | 2.92 | 3.56 | 5.22 | 7.64 | 8.73 |
$150 | 1.78 | 2.19 | 2.67 | 3.91 | 5.73 | 6.54 |
$100 | 1.19 | 1.46 | 1.78 | 2.61 | 3.82 | 4.36 |
Extended Plan – Monthly Rates
Monthly Benefit | Age Range | |||||
---|---|---|---|---|---|---|
18 – 29 | 30 – 39 | 40 – 49 | 50 – 59 | 60 – 64 | 65 – 69* | |
$1,200 | $16.56 | $21.96 | $27.96 | $45.60 | $58.44 | $52.64 |
$1,150 | 15.87 | 21.04 | 26.79 | 43.70 | 56.00 | 50.45 |
$1,100 | 15.18 | 20.13 | 25.63 | 41.80 | 53.57 | 48.25 |
$1,050 | 14.49 | 19.21 | 24.46 | 39.90 | 51.13 | 46.06 |
$1,000 | 13.80 | 18.30 | 23.30 | 38.00 | 48.70 | 43.87 |
$950 | 13.11 | 17.38 | 22.13 | 36.10 | 46.26 | 41.67 |
$900 | 12.42 | 16.47 | 20.97 | 34.20 | 43.83 | 39.48 |
$850 | 11.73 | 15.55 | 19.80 | 32.30 | 41.39 | 37.29 |
$800 | 11.04 | 14.64 | 18.64 | 30.40 | 38.96 | 35.09 |
$750 | 10.35 | 13.72 | 17.47 | 28.50 | 36.52 | 32.90 |
$700 | 9.66 | 12.81 | 16.31 | 26.60 | 34.09 | 30.71 |
$650 | 8.97 | 11.89 | 15.14 | 24.70 | 31.65 | 28.51 |
$600 | 8.28 | 10.98 | 13.98 | 22.80 | 29.22 | 26.32 |
$550 | 7.59 | 10.06 | 12.81 | 20.90 | 26.78 | 24.13 |
$500 | 6.90 | 9.15 | 11.65 | 19.00 | 24.35 | 21.93 |
$450 | 6.21 | 8.23 | 10.48 | 17.10 | 21.91 | 19.74 |
$400 | 5.52 | 7.32 | 9.32 | 15.20 | 19.48 | 17.55 |
$350 | 4.83 | 6.40 | 8.15 | 13.30 | 17.04 | 15.35 |
$300 | 4.14 | 5.49 | 6.99 | 11.40 | 14.61 | 13.16 |
$250 | 3.45 | 4.57 | 5.82 | 9.50 | 12.17 | 10.97 |
$200 | 2.76 | 3.66 | 4.66 | 7.60 | 9.74 | 8.77 |
$150 | 2.07 | 2.74 | 3.49 | 5.70 | 7.30 | 6.58 |
$100 | 1.38 | 1.83 | 2.33 | 3.80 | 4.87 | 4.39 |
Select Plan – Monthly Rates
Monthly Benefit | Age Range | |||||
---|---|---|---|---|---|---|
18 – 29 | 30 – 39 | 40 – 49 | 50 – 59 | 60 – 64 | 65 – 69* | |
$6,000 | $50.35 | $68.03 | $98.65 | $176.88 | $227.23 | $254.27 |
$5,750 | 48.25 | 65.20 | 94.54 | 169.51 | 217.76 | 243.67 |
$5,500 | 46.15 | 62.36 | 90.43 | 162.14 | 208.29 | 233.08 |
$5,250 | 44.05 | 59.53 | 86.32 | 154.77 | 198.82 | 222.48 |
$5,000 | 41.96 | 56.69 | 82.21 | 147.40 | 189.35 | 211.89 |
$4,750 | 39.86 | 53.86 | 78.10 | 140.03 | 179.89 | 201.89 |
$4,500 | 37.76 | 51.02 | 73.99 | 132.66 | 170.42 | 190.70 |
$4,250 | 35.66 | 48.19 | 69.88 | 125.29 | 160.95 | 180.10 |
$4,000 | 29.60 | 40.00 | 58.00 | 104.00 | 133.60 | 149.47 |
$3,900 | 28.86 | 39.00 | 56.55 | 101.40 | 130.26 | 145.73 |
$3,800 | 28.12 | 38.00 | 55.10 | 98.80 | 126.92 | 141.99 |
$3,700 | 27.38 | 37.00 | 53.65 | 96.20 | 123.58 | 138.26 |
$3,600 | 26.64 | 36.00 | 52.20 | 93.60 | 120.24 | 134.52 |
$3,500 | 25.90 | 35.00 | 50.75 | 91.00 | 116.90 | 130.78 |
$3,400 | 25.16 | 34.00 | 49.30 | 88.40 | 113.56 | 127.05 |
$3,300 | 24.42 | 33.00 | 47.85 | 85.80 | 110.22 | 123.31 |
$3,200 | 23.68 | 32.00 | 46.40 | 83.20 | 106.88 | 119.57 |
$3,100 | 22.94 | 31.00 | 44.95 | 80.60 | 103.54 | 115.84 |
$3,000 | 22.20 | 30.00 | 43.50 | 78.00 | 100.20 | 112.10 |
$2,900 | 21.46 | 29.00 | 42.05 | 75.40 | 96.86 | 108.36 |
$2,800 | 20.72 | 28.00 | 40.60 | 72.80 | 93.52 | 104.63 |
$2,700 | 19.98 | 27.00 | 39.15 | 70.20 | 90.18 | 100.89 |
$2,600 | 19.24 | 26.00 | 37.70 | 67.60 | 86.84 | 97.15 |
$2,500 | 18.50 | 25.00 | 36.25 | 65.00 | 83.50 | 93.42 |
$2,400 | 17.76 | 24.00 | 34.80 | 62.40 | 80.16 | 89.68 |
$2,300 | 17.02 | 23.00 | 33.35 | 59.80 | 76.82 | 85.94 |
$2,200 | 16.28 | 22.00 | 31.90 | 57.20 | 73.48 | 82.21 |
$2,100 | 15.54 | 21.00 | 30.45 | 54.60 | 70.14 | 78.47 |
$2,000 | 14.80 | 20.00 | 29.00 | 52.00 | 66.80 | 74.73 |
$1,950 | 14.43 | 19.50 | 28.27 | 50.70 | 65.13 | 72.86 |
$1,900 | 14.06 | 19.00 | 27.55 | 49.40 | 63.46 | 71.00 |
$1,850 | 13.69 | 18.50 | 26.82 | 48.10 | 61.79 | 69.13 |
$1,800 | 13.32 | 18.00 | 26.10 | 46.80 | 60.12 | 67.26 |
$1,750 | 12.95 | 17.50 | 25.37 | 45.50 | 58.45 | 65.39 |
$1,700 | 12.58 | 17.00 | 24.65 | 44.20 | 56.78 | 63.52 |
$1,650 | 12.21 | 16.50 | 23.92 | 42.90 | 55.11 | 61.65 |
$1,600 | 11.84 | 16.00 | 23.20 | 41.60 | 53.44 | 59.79 |
$1,550 | 11.47 | 15.50 | 22.47 | 40.30 | 51.77 | 57.92 |
$1,500 | 11.10 | 15.00 | 21.75 | 39.00 | 50.10 | 56.05 |
$1,450 | 10.73 | 14.50 | 21.02 | 37.70 | 48.43 | 54.18 |
$1,400 | 10.36 | 14.00 | 20.30 | 36.40 | 46.76 | 52.31 |
$1,350 | 9.99 | 13.50 | 19.57 | 35.10 | 45.09 | 50.44 |
$1,300 | 9.62 | 13.00 | 18.85 | 33.80 | 43.42 | 48.58 |
$1,250 | 9.25 | 12.50 | 18.12 | 32.50 | 41.75 | 46.71 |
$1,200 | 8.88 | 12.00 | 17.40 | 31.20 | 40.08 | 44.85 |
$1,150 | 8.51 | 11.50 | 16.67 | 29.90 | 38.41 | 42.97 |
$1,100 | 8.14 | 11.00 | 15.95 | 28.60 | 36.74 | 41.10 |
$1,050 | 7.77 | 10.50 | 15.22 | 27.30 | 35.07 | 39.23 |
$1,000 | 7.40 | 10.00 | 14.50 | 26.00 | 33.40 | 37.37 |
$950 | 7.03 | 9.50 | 13.77 | 24.70 | 31.73 | 35.50 |
$900 | 6.66 | 9.00 | 13.05 | 23.40 | 30.06 | 33.63 |
$850 | 6.29 | 8.50 | 12.32 | 22.10 | 28.39 | 31.76 |
$800 | 5.92 | 8.00 | 11.60 | 20.80 | 26.72 | 29.89 |
$750 | 5.55 | 7.50 | 10.87 | 19.50 | 25.05 | 28.02 |
$700 | 5.18 | 7.00 | 10.15 | 18.20 | 23.38 | 26.16 |
$650 | 4.81 | 6.50 | 9.42 | 16.90 | 21.71 | 24.29 |
$600 | 4.44 | 6.00 | 8.70 | 15.60 | 20.04 | 22.42 |
$550 | 4.07 | 5.50 | 7.97 | 14.30 | 18.37 | 20.55 |
$500 | 3.70 | 5.00 | 7.25 | 13.00 | 16.70 | 18.68 |
$450 | 3.33 | 4.50 | 6.52 | 11.70 | 15.03 | 16.81 |
$400 | 2.96 | 4.00 | 5.80 | 10.40 | 13.36 | 14.95 |
$350 | 2.59 | 3.50 | 5.07 | 9.10 | 11.69 | 13.08 |
$300 | 2.22 | 3.00 | 4.35 | 7.80 | 10.02 | 11.21 |
$250 | 1.85 | 2.50 | 3.62 | 6.50 | 8.35 | 9.34 |
$200 | 1.48 | 2.00 | 2.90 | 5.20 | 6.68 | 7.47 |
$150 | 1.11 | 1.50 | 2.17 | 3.90 | 5.01 | 5.60 |
$100 | 0.74 | 1.00 | 1.45 | 2.60 | 3.34 | 3.74 |
Rates and/or benefits may be changed on a class basis. Rates are based on the attained age of the insured and increase as you enter each new age category. Rates shown above are rounded to the nearest penny. Please note that your bill will reflect the exact premium. For your convenience, you will be billed on a quarterly basis.
*Renewal rates only
Disability Form Series includes GBD-1000, GBD-1200, or state equivalent
70571
Underwritten by: Hartford Life and Accident Insurance Company
Hartford, CT 06155
(AGP-5883 and AGP-5884)
May not be available in all states.
When Coverage Begins: You or your spouse’s coverage begins on the first day of the month following the Administrator’s approval of your application, provided you are Actively At Work, meet any applicable evidence of insurability requirements, and have paid your premium. If on the date you or your spouse are to become covered, you or your spouse are not Actively At Work, coverage will not begin until the date you are Actively At Work for 1 month.
When Coverage Ends: As long as you’re Actively At Work, except due to Total Disability covered by the Policy, pay your premiums when due, and the Master Policy remains in force, you can keep this plan until you reach age 70. If you cease to be Actively at Work due to a temporary lay-off or leave of absence, your coverage will continue for 26 weeks, provided you pay the required premium.
Exclusions: The Policy does not cover Disability or loss caused by intentionally self-inflicted Injury, suicide or attempted suicide, while sane or insane; pregnancy or childbirth, except Complications of Pregnancy; war or act of war, whether declared or undeclared; or Your commission or attempted commission of a felony.
Pre-Existing Conditions Limitation: Benefits will not be paid for any loss or period of Total Disability that begins during the first year of your insurance and which is a result of a Pre-existing Condition. A Pre-existing Condition means any Disability, diagnosed or undiagnosed, for which medical care is received by you: within the one-year period prior to the date your insurance starts; or with respect to any increase in coverage, within the one-year period prior to the effective date of your increase in coverage.
Recurrent Disability: if you cease to be Totally Disabled and return to work for a total of 10 days or less during the Elimination Period, the Elimination Period will not be interrupted. Periods of Disability separated by at least 3 months, during which You are Actively at Work, will be considered separate Periods of Disability.
Definitions:
Applicable to the Basic Plan and Extended Plan: Disability or Totally Disabled means disability which: 1) during the Elimination Period and the first 60 months during which Total Disability Benefits are payable, wholly and continuously prevents you or your spouse from performing the essential duties of you or your spouse’s occupation.
Applicable to the Select Plan: Disability or Totally Disabled means disability which: 1) during the Elimination Period and the first 24 months during which Total Disability Benefits are payable, wholly and continuously prevents you or your spouse from performing the essential duties of you or your spouse’s occupation; and 2) after that, wholly and continuously prevents you or your spouse from engaging in any occupation.
Elimination Period means the number of consecutive days at the beginning of any one period of Total Disability which must elapse before benefits are payable.
Actively At Work means you or your spouse are performing all the essential duties of your or your spouse’s occupation for wage or profit on a full-time basis (at least 30 hours per week).
Any Occupation means any occupation for which you or your spouse are qualified by education, training or experience, and that has an earnings potential greater than the lesser of: the amount of you or your spouse’s Pre-Disability Earnings and the benefit period percentage; or the maximum monthly benefit.
Current Monthly Earnings means monthly earnings you or your spouse receive from you or your spouse’s employer, and other employment, while you or your spouse are Totally Disabled.
Pre-Disability Earnings
- for sole proprietor, partners, and shareholders in a S-Corporation means the monthly average of earnings reported as “net earnings from self-employment” for federal income tax purposes for, the 3 tax year(s) immediately prior to the last day You were Actively at Work before You became Disabled; or the 1 tax year immediately prior to the last day You were Actively at Work before You became Disabled if employed for less than 3 calendar years; or with respect to Partners and shareholders in a S-Corporation, the average draw during their period as a partner or shareholder, if less than the above period;
- for all others not defined above means your regular gross monthly rate of pay based on your statement of wages earned and taxes withheld (Form W-2) for the one-year period immediately prior to the last day you were Actively At Work before you became Totally Disabled; or the total number of calendar months immediately prior to the last day you were Actively At Work before you became Totally Disabled, if less than the above period.
Injury means bodily injury resulting directly from an accident and independent of disease or bodily infirmity which occurs while You or Your Spouse are covered under The Policy. However, an Injury will be considered a Sickness if Your or Your Spouse’s Disability begins more than 30 days after the date of the accident.
Sickness means a Disability or loss which is (1) caused by any condition, illness, disease or disorder of the body; any infection, except a pus-forming infection of an accidental cut or wound or bacterial infection resulting from an accidental ingestion of a contaminated substance; hernia of any type unless it is the immediate result of an accidental Injury covered by the Policy; or Complications of Pregnancy; or (2) caused by any medical or surgical treatment for a condition shown in item (1) above.
Acceptance into this plan is subject to medical evidence of insurability as determined by The Hartford 1. Depending on your age, the amount of coverage you request, and your answers on the application, a medical examination, medical test(s), or other evidence of good health may be required. Any exams/tests requested by the company will be conducted at your convenience and at no expense to you.
This policy provides disability income insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York Department of Financial Services.
This brochure explains the general purpose of the insurance described, but in no way changes or affects the Master Policy AGP-5883 and AGP-5884 as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in full or discontinued. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy issued to the policyholder. This program may vary and may not be available to residents of all states.
A.G.I.A., Inc. is the Plan Administrator that administers the insurance plan on behalf of the Hartford Life and Accident Insurance Company for the benefit of the Group Policyholder. NASW/ASI is compensated for the placement of insurance and for the services it provides to customers on behalf of the insurance company, in addition to other compensation it may receive. Additionally, compensation is paid to or retained by the Group Policyholder directly or indirectly for services associated with this insurance program.
Endorsed by:
Underwritten by:
Hartford Life and Accident Insurance CompanyHartford, CT 06155
1The Hartford Financial Services Group, Inc. (NYSE: HIG) operates through its subsidiaries under the brand name, The Hartford, and is headquartered in Hartford, Connecticut. For additional details, please read The Hartford’s legal notice at www.thehartford.com.
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MA Notice of Insurance Information Practices
Administered by:
A.G.I.A., Inc.
P.O. Box 26450, Phoenix, AZ 85068
Disability Form Series includes GBD-1000, GBD-1200, or state equivalent
70571
Underwritten by: Hartford Life and Accident Insurance Company
Hartford, CT 06155
(AGP-5883 and AGP-5884)
May not be available in all states.
To apply, please click on your state of residence below for a printable application. If you do not see your state below, we are working on adding more states applications. Please check back at a later time.
Please mail your completed application to:
NASW Assurance Services
Group Insurance Program Administrators
PO Box 26450
Phoenix, AZ 85068-9955
Alabama | Arizona | Arkansas | Colorado | Delaware | District of Columbia | Georgia | Hawaii |
Iowa | Louisiana | Michigan | Mississippi | Montana | Nebraska | Oklahoma | Pennsylvania |
Rhode Island | South Carolina | Wisconsin | Wyoming |
Disability Form Series includes GBD-1000, GBD-1200, or state equivalent
70571
Underwritten by: Hartford Life and Accident Insurance Company
Hartford, CT 06155
(AGP-5883 and AGP-5884)
May not be available in all states.