Evidence/Proof of Insurability for Group Life Insurance

L419-548A Page 3 ORIGINAL TO THE HARTFORD (Revised 3/2004) SB127329E1 Administered by: Underwriting Company (herein called the “Company”): Group Life Evidence/Proof of Insurability CNA Group Life Assurance Company* Continental Assurance Company PLEASE TYPE OR PRINT CLEARLY WITH BLUE OR BLACK INK Part 1: Employer/Association Information Group Policy #(s):

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