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1 22222222re py h2vspi2q y 2sx exgi2gyw ex re py h2vspi2exh2eggshix 2sx exgi2gyw ex vie i22 ii22 re 22evv22 ig syx 22e i22p vv 22gyw vi ih22exh22 sqxihF22py e h22 rigyw vi ih22e vsge syx22 y22 y 22re py h22fixips 22wexeqiwix 22 i sgi22gix i FvgESIVHEIV2 2 HVGHR 2@ 2 2 F FeFA22e vsge syx22py 22 ry 22 i w2hs efsvs 22sxgywi22fixips 2 2 2 2 2 2 2 D2 2 X 2222222s2222i ! "#$2 2E2 2 2 2 2 2 ! "#$2 2 222222ss2222i ! #$2 2E2 2 2 2 2 2 ! 2 2 2 2 2 2h 2 F 22222sss2222e& ' " ( 2 2y 2s * " 2E2 2 2 2 2 2 ! F 22222s 2222e , -2 '!$ #$2 2E2 2 2 2 2 2 2 2 2 2 ! Fh 2 2 2 G 2 2 2 cv h2222222222222222272 2 2 2 c22@ 2s 2 2 ISEe2 2 2 2 2 2 2 FA 2 2 2 2 2 2 2 h2 c2222 22222222222x i 9 2e 2@ D2g D2 D2 AeF2s 2e 2 2i fF2s 2e 2 2i 222i ! "9$2 2 22s 2f 2g 2 2 2i 22x 222s 24x D42 2 2 2 2 c 2222222x v 2 2 2 2 y 2 2 D2 2 2 2 2 2 2 chF2s 2e 2 2g r 2 22 2 22w2E2py f 2 2 2 G 2 2 2 2 - 2 2 2Q2 D2 2 / 2 2 2 h222222222222222227gF2s 2x 22 2 "2 2 "2 $ %h 2v - 2 2e 2 2 2p 22v - 2e h 2 h282v h2 2 2 2 2p 2v - c22222222222222222222222222 2222222222222222x 2 2 2 2 2p 2v - 2 2 2 / c22222 222222222222x s 24 D42 2 - 2 2 - 2 2 2 - / F22222p 22 / vgESIVHEIV2 2 HVGHR 22222@IAs 22iw vy ii2ix yvvih2sx2 ri2re py h9 2vyxq2 i w2hs efsvs 2 vex2c i 2222222xysp24 i D42ippig s i2he i 2 2 2 2@i 9!)

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3 2 2 2 2 ! 2 !! ! AcrF2 " 22@22222222222222222A@222222222222222222 Ax 2@ 2 2 2 A22222222222222 h 222222222222222222 2x 2222222222222222222222222222222222222222 2222222222222p 2x e 2g e 2g g 2 26 2 2 2 2 /2 /2 2 /c22222222222 222222222222x 777qF2s 2e 2 2t 2 %2 2 %2 2 2h % iF2s 2e 2 22 2222222222x s 24 D42 Fg ( ( )) (v (e 2 2222222222222222222222222h % 22222222222222222222p 3 2222222222222222222 " %F %F %F %F ( ), ( (f ) ( (u ) (g (g /) ( (G , (2y u 2 G 2r 2w g) (g 2 26 2 2 2 2 2 2 2 2 2 2 c22222222222 22222222222x 2222s 2< D=2 X 2x 22@2222222222222A22222 2222222222x 222s 24 D42 Fr - 2 2 D2 2 2 2 2 2 2 2 92g 2 c22222222222 22222222222222x 22222s 24x D42 F 2f 2g 2 !2 " 2i ! 22@2fi2 i2 y2ex i 2evv2 i syx 2E2pesv i2 y2hy2 y2we 2hive 2 y 2gvesw2Ae 2@ Ag G 22222w 222222222222222222 / 22222222222222222 22222p 222222222222222w 222222222222222222h - hF2s 2e 2 2h % v 2 2 2 2 2 2 22222h 2 2 2 2 2 c22222 2 222222222x 2222222h 2 2 2 2 2 2 s 24x D42 F 2 2 D2 - 2 2 2 2 c22222 22222x s 2 2 - 2 2 2 2 D2 2 2 2 c 2222 2 2@ A222222222222222p 2 2@ A2x s 24 D42 2 2 2 D2 2 2 2 2 F22eF2s 2e 2 iF2s 2e 2 $2 "@2222222222222Ae 2g @w 22222@h A222222222@ A@w 22222@h A222222222@ A2222222 2@ F FD2 G AD2 2 2 2 2 2 6 2 ch 2 2 2 2 2 2 2 x 2 2 e 2 2 - /2 2 / 2 222222222 92g 222222222222 2h 2222222222222x 2p 2h 22222222222y s 24 D42 2 2 2222222222222222 2 2 2 2 2 2e 262222222222222222222h 2 2 2222222222222222222222h 2 2 2i s 2 2 2 2 2 2 c 2x h 2 2f 2@w D2h D2 A 2i 2@ 2 + !))))))))

4 D2 2 A22 222222x 2 2 2 2 2 2 2 2 2 c2v 2 p 22222222222222222222222222222w ) 2s )2222222222222 2 2x 22222222gF2p 2s %%D2s 9 2 2 " D2 %: 2 2 : "23 % %2e 2 2 @w A222222@h A2222222222@ A22222222fF2p 2 2s 9 D2 %: 2 2 : "23 % %i ! 9$22 22ss2222222e vsge syx222py 222 ry 222 i w222hs efsvs 222sxgywi222fixips 222222222222re py h22vspi22q y 22sx exgi22gyw ex 2222222re py h22vspi22exh22eggshix 22sx exgi22gyw ex p 2 2 7 2 2 2 2 22 2 2 2 2 2 2 2 2 2 2 2 F222 2 2 2 7 2 2 2 2 2 2 2 2 2 2 2 2 2 2 /2 2 D2 2 2 2 2 2 2 D2 2 D2 2 D2 2 2 2 2 F22s 2 2 2 2 2 2 D2 2 2 2 2 2 2 2 2 2 2 2 2 2 F22 2 2 2@ 2 26 PHFHH2 2 AX262222222222222 FHHFvgESIVHEIV2 2 HVGHR 22222@PAf 2 2 2 /D2 2 2 2 7 2 2 2 / 2 26 D2 2 2 2 2 2 26 cs 24 D42 Fp 2 2 2g X22s 2 2 2 2 2 2 D2 D2 2 2 2 2 2s 2g 2 2 2 2 2 2 2 2 2 2 F22 2 2 2 D2 D2 2 2 D 2 2 F2e 2 2 2 2 2 2 2 2 2 D2 D2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 22 2 2 2 2 2g 2h 2 2s Fp "2" $ , $2 *2 2$ $2i gi 22g * " D2p " , D2x 02t "$ !

5 D2g " , D2 $! 2 D22e"3 $ $Dx 02w 4 D2v & $ D2x 02 "3D2y" - D2 ,2 "- X22e2 2 2 2 2 2 2 2 2 D2 2 2 2 2 2 2 2 2 2 2 D2 X2@ A2 2 2 2 2 2 2 2 2 2 2 2 2 D2 2@ A2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 F22e2*" &,& 2 $&" 2 2 $2 2 " F 2r 2 2 2 2 2 2 2 2 2 2 2 2 $ 2 2 2 Fp "2" $ , $2 *2p " , X22e 2 2 2 2 2 2 2 2 % D2 D2 2 2 2 2 2 2 2 2 2 2 2 2 2 D2 2 2 2 2 2 2 2 2 2 2 2 Fp "2" $ , $2 *2x 02t "$ !D2e"3 $ $D2 ,2x 02w 4 X222e 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 % 2 2 2 2 2 F22e 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 % 2 2 2 2 2 Fp "2" $ , $2 *2 $! 2 X222e !2 "$ 20' 23 0 - !2 ,20 '2 2 2, *" &,2 !2 $&" 2 !2 " ' "2 "$ 2* $2 2 2* "2 $&" 2 "2$ 2 *2 2 -2 !2 " !2* $ 2 * " "2 $2* "2 ' 2 &" $ 2 *2 $ , -D2 * " 2 " -2 !2* 2 " 2 ' " 2 $2 2*" &,& $&" 2 D20' '2 $2 2 " 2 ,2$& 6 $2 2 "$ 2 2 " 2 ,2 2 2 $Fpy 2 i shix 2yp2gevspy xseX22py 2 y 2 y ig syxD2gevspy xse22ve 2 i s i 2 ri2pyvvy sxq2 y2e ie 2yx rs 2py wX224ex 2 i yx2 ry2uxy sxqv 2 i ix 22e2pev i2y 22p e h vix 2gvesw2py 2 ri2 e wix 2yp2e2vy s 22q sv 2yp2e2g swi2exh22we 2fi2 ftig 2 y2psxi 2exh2gyxpsxiwix 2sx2 e i2 s yxF4p "2" $ , $2 *2v & $ X22e 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 % 2 2 2 2 2 Fp "2" $.

6 $2 *2x 02 "3X22e 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 D2 2 2 2 2 2 D2 2 2 2 2 2 D2 2 2 2 2 D2 2 2 D2 2 2 2 2 % 2 2 2 2 2 2 2 $ 2 2 2 2 2 2 2 2 2 2 2 2 2 FpF22 - &" 2 2 $ 2 2 2 @ A2 2 2 22 2 2 2h2 2 2 D2s2 2 2 2 2 2s 2 2 2 2 2 2 2 2 2 2 2 D2 $ 2 2 2r 2h 2s F22p D2s 2 2 2s2 2 2 2 22 2 2 2 2 2 22 2 2 2 2 2r 2 2 2 2 D2s2 2 2 2 2 2 2r D2 Fs 2s2 2 2 2 2 2 2 2 2 2 2 D2s2 2 2s2 2 2 ) 2 2 2 2 2 2 2 2 2 F22 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Fe vsge syx22py 22 ry 22 i w22hs efsvs 22sxgywi22fixips 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 F sqxe i2yp2 ri2iw vy ii22222he i 222222222 vgESIVHEIV2 2 HVGHR 22222@RAQF22s 2 2 2 2 D2 D2 2 2 2 D2 2 2 D2 22222 2 D2 2 D2 2 2 2 2w 2f 2 Fs2 2 2 2 2 2 2 X2@ A2r 2p 2s 2g D2r 2v 2s 2g D2r 2v 2e 2s 2g D2r 2v 2q 2s 2g D2 2 2 2 2 2 2 2 2 2 D2 2 2 2 2r Y2 2@ A22 2r 9 2 D22 2 2 2 2 2 2 2 2 2 D2 2 2 2 2 PF22 2 2 2 D2 D2 2 2 2 D2% 2 D2 2 2 2 D2 2 D222222 2 2 2 2 E 2 2 2 2 2 Y2 2 2 2 2 22222 2 2 D2 2 2 2 2 2 2 2 2 2 2 Y2 2 D22222 D2 2 2 2 D2 2 2 2 2 Y2 2 2 D2 F FD2 2f D22222 2 Y2 2 2 2 2 2 2 D2 2 D2 2 2 2 2 2 22222 Y2 2 2 F 2 D2 2 D2 2 2 2 D2 2 2 D2 D2 2s $ D2 2 D2 2 D2 2 2 D2 2 D2 22p D2 2 2v 2q 2e D2 2 2 2e 2 2 2e F2222 ( 2 2s

7 22 2q 2 2s 2@ 2! 2 2q Ah yX22e 2 D2 2 D2 D2 D2 2 2 2 2 2 E 2 2 2 2222222 2 2 2 2 2 2 Ys2 2 2 2 2 2 2 2 2 2e 2 2 2 2 2 2 2 2 2 2 2 2 2 F22e 2 2 2 2 2 2 2 2 2r 2 2 2 2 2i gi 2 2 2 2 2 2 D2 2s $2 D2 2 2 2 D2 2 2 2 2 2 2 2 2 2 2 2 2 2 2g D2 2 2 2 2 2 ) D2 2 2s2 2 2 D2 2 2 2 2 2 2 2 2 2 2 2 2 2 Fs2 2 2s2 2 ) 2 2 2 2 2 2 2e F 2e 2 2 2 2 2 2 2 2 2 F22s2 2 2 2 2 2 2 2 2 2 2 Fe2 2 2 2 2 2 2 2 2 2 2 2 FIF22e 2 2 2 2 D2 2$E 2 D2 2 2 2 D2 2 D2 D22222 2 2 2 $ D2 2 2 F22p 2 2 2 2 D2 2 22222 2 2 2 2 2rs Gesh D2 2 D2 2 2 2 D22222 2 2 D2 2 2 2 2 2 2 2 2 2 F2222222222222222222@h 2 2f A2222222@ 2 2x A22s 9 2x 2@ 2 FAe vsge syx22py 22 ry 22 i w22hs efsvs 22sxgywi22fixips 22 22ssse& ' " ( 2 2y 2 ,2 $ 2s * " vgESIVHEIV2 2 HVGHR 2222@SAh 2 2 2 2- r 2 2 2 2 2 2 2 c 222222222x 222h @ A 2 / 2 c222222 2222222222x 22s 24 D422h 22222222222222222222 2222222222222222222222222222222222222222 2222222222222222222222222g 2g h 2 2 2 2 2 2 2 Xs 2 2 2 2 2 D2 2 2 2 2 - 2 D2 2 2 2 / X2222222x 2 2 2 2 Y2 2 2 - 2 D2 2 F222222222w 2 2 - 222222222v /2SH2 F2 2 2 7 2 /2 G 2 /2 2 6 2 / /2 2 2PS2 FA222222222 / 2 2 2 2 Y2 2 2 / 2 222222222v /2PH2 F2 2 2 7 2 /2 G 2 /2 2 6 2 / /2 2 2IH2 F2i- 2 / 2 2 / 2 222222222 2 2 2 2 / / 2 D2 26 2 2 2 2 / 2 2 2 - - 2 /2 2 2 2 2 2 2 / 2 2 /222222222 2 /2 2 2 G 2 /2 D2 2 2 2 7 2 /2 2 /2 2 2 / 2 / FA222222222w 2 2 2 2 Y2 2 2 G - 2@ A2 - 222222222@v /2IH2 F2 2 2 2 /2 G 2 /2 F2e / 2 2 26 2 2 2 2 2 222222222 - - 2 /D2 2 2 2 2 /2 2 /2 2 2 2 2 /2 26 2 FA222222222 - 2 2

8 2 2 Y2 2 2 2@ A2 - e , -2 '!$ 9$2 s 2 / D2 2 2 2 2 2 2 - cw 22222222222222h 222222222222 22222222222vw 2h 52 22iFsFxF25h / 22222222222222222222222 2e g 2g 9 2x 2222222222222 x22222222222222hFyFfF22222222222222222r / 2222222222222222 / f 2 @ A22222222@h A222222222222@h A h 222222 h 222222 s 2 2 2 2 2 2 2 2 6 2 2 2 2 c222222222 2x X 9 2 2 2 2 2 s s 6 / w Gx - 2g h / 2@ 2 22 AsghW2g 6 - 2 2p / 2@ 2 2 2 D2 2 2 Ah 2 2 2 2 2 cvgESIVHEIV2 2 HVGHR 222222222222222222222222222@TA / h 2 / / 2@ 2 2 A - s - / / rs y hseqxy s sw es wix ie wix e vsge syx2py 2 ry 2 i w2hs efsvs 2sxgywi2fixips 22222222222222222 ( )2s e /2 9 2x 22222222222222222222222 25X2222222222222222222222222222222222222 2222222222p 2522222e 2g 2222222222222222222222e 2g @2222222222222222A2222222222222222222222 22222222222222222222@2222222222222222A 2 2 2 9 2 2 2 2 2 c 2 2 2 2 2@ 2 Ac@w A@h A22222222222222222222@ A@w A222222222222222222222@h 2A22222222222222222222@ Ax 2 2e 2 2r @ A 2 2 F 2 2 2 c 222 2222x 222s 24 D42 @ A2 @ A2 / x 2 2 2 2 2 2@ 2 G As 24 D42 2 2 22222222 v 2 2 2 2 2 2 2 2 2 2 2 @v /2 IHH2 F2 2 2 7 2 /2 G 2 /2 6 2 / /2 2 2SH2 FAs 7 2 2 2 2 Fi 2/ 2 /2 2 2 F22y 2 2 2 - F / 2 2 2 2 /D2 2/ 2 /2 F22r 2 2 / 2 2 Fw 2 2 2 2 /F22v 2 2 /2 2 2 Fw 6 2 2 2 - 2 EE D2 2 F22e- 2 - D2 / 2 D2 2 2 2 Fs 2 2 2 2 2 2 FShortTerm disability (Fully Insured)

9 Hartford Life Insurance CompanyHartford Life and Accident Insurance CompanySampleCompleted short TermDisability claim FormEmployer s employee became insured underthis plan? This is usually the dayfollowing completion of the EligibilityWaiting Period for the group policy. Ifthe employee was a late enrollee,however, the effective date is the date theemployee s Personal Health Statementwas approved by The needed for withholding andreporting taxes. This information isimportant because it determines theamount of taxable wages and/orbenefits that should be reported for theemployee. The portion of the benefitfunded by you is day employee actually worked?This is the actual last day the employeeworked, not the date through whichearnings or sick pay were about the employee ssalary.

10 This information should bebased on the policy s specific definitionof Weekly Earnings. If you recordearnings asan hourly rate, please besure to include the number of hoursworked in a regular s Statement(Continued)4 Employee s Income Since the STD benefitrate may be affected by the amount ofother income benefits you receive or areeligible to receive, it s important that youcomplete this section s Statement(Continued)Authorization to Obtain and Release InformationThe employee completes and signs Physician s StatementThis statement is to be completed by thephysician who is treating the disability (Fully Insured)Hartford Life Insurance CompanyHartford Life and Accident