ENROLLMENT FORM AND PAYROLL DEDUCTION AUTHORIZATION
GUARANTEE ISSUE ACCIDENT INSURANCE PLAN
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

To avoid delay please answer all questions in the application carefully.

PLEASE ENTER YOUR
Full Name:
Social Security #:
Address:
City:
State:
Zip Code:
Email Adddress:
Date of Birth:
Occupation:
Annual Salary: Marital Status:
I am a Full Time Employee working 25 or more hours per week
Plan Desired:

Employer:
STATE OF FLORIDA

Select Agency:

Select Amount of Principal Sum Desired To Display
Monthly or Bi-Weekly Payroll Deducted Premium

Select Amount
Monthly Premium:
Select Amount
Bi-Weekly Premium: 

Beneficiary:

Relationship:
Employee is beneficiary for spouse and children


I authorize my employer to deduct
the following amount from my salary:
Total Amount:

UNDER PAYROLL DEDUCTION CODE 442

The amount so deducted is to be paid each month to Anthony Finaldi & Co., Inc.
755 Benjamin Chaires Road, Tallahassee, Florida 32317,
On behalf of the Insurance Companies to cover premiums on a policy
or policies of insurance applied for by me:
This Authorization shall remain effective until:
(a) I submit a new authorization changing the amount of each deductions, or
(b) I request that this authorization be canceled, or
(c) Termination of my employment.

Date of Application:
Signature:


APPLICANT: To obtain coverage
Print, Sign and Mail To:
Administrator
ANTHONY FINALDI & CO., INC.
755 Benjamin Chaires Road, Tallahassee, Florida 32317
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
Policy #21-ADD-S05516


For your Protection and Security,
Please Clear Your Application After Printing.


PRIVACY STATEMENT


©2004

Email: AFINALDI@worldnet.att.net

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