To all New York certificate holders:
New York’s domestic violence law provides, in relevant part, that if any person covered by an insurance policy
delivers a valid order of protection to the insurer then the insurer is prohibited for the duration of the order from
disclosing to the policyholder or other person the address and telephone number of the insured, or of any person
or entity providing covered services to the insured. If a child is a covered person, then the right established by
this section may be asserted by the child’s parent or guardian.
This law also requires a health insurer to accommodate a reasonable request made by a person covered by an
insurance policy to receive communications of claim-related information by alternative means or at alternative
locations if the person clearly states that disclosure of the information could endanger the person. If a child is
the covered person, then this right may be asserted by the child’s parent or guardian.
The Hartford has established procedures so that our New York certificate holders who are victims of domestic
violence or are otherwise endangered may receive claim-related information by alternative means or at
alternative locations. However, if you have filed a claim with a third-party administrator (TPA), you must
contact your TPA in order to take advantage of these procedures.
If you have filed a life or health claim, you may take advantage of these procedures by either delivering a valid
order of protection or making a reasonable request by completing and submitting a Confidential Communication
Request Form to The Hartford or your TPA. A reasonable request will never require any justification.
You may make a reasonable request via telephone as long as you follow up with the submission of a completed
Confidential Communication Request Form to The Hartford or your TPA. If you have multiple claims with The
Hartford and/or a TPA, you must submit a reasonable request for each claim. You may revoke a reasonable
request by submitting a separate written, notarized communication to The Hartford or your TPA.
If you have filed a life or health claim with The Hartford and would like further information on or to take
advantage of these procedures, please contact your personal Hartford claim analyst or send your Confidential
Communication Request Form to the appropriate address or fax number listed below. However, if you have
filed a claim with a TPA, then you must contact your TPA in order to take advantage of these procedures.
For Short-term and Long-term Disability:
The Hartford
P.O. Box 14301
Lexington, KY 40512-4301
Fax Number: (866) 411-5613
For Leave Management:
The Hartford
P.O. Box 14285
Lexington, KY 40512-4285
Fax Number: (877) 588-4817
For Group Life and Accident:
The Hartford
P.O. Box 14299
Lexington, KY 40512-4299
Fax Number: (866) 954-2621
For Blanket Lines:
The Hartford
P.O. Box 3856
Alpharetta, GA 30023
Fax Number (866) 954-3993
For further information on domestic violence services, you may contact the NYS Domestic and Sexual Violence
Hotline by dialing 1-800-942-6906 or by accessing the website for the New York State Office for the Prevention
of Domestic Violence at the following link: http://www.opdv.ny.gov/help/dvhotlines.html.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life
Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT.
CONFIDENTIAL COMMUNICATION REQUEST FORM
__________________________________________________________________________________________
This form is for use by a person who is covered by insurance and wishes to make a reasonable request to receive
communications of insurance claim-related information from The Hartford by alternative means or at alternative
locations if disclosing claim-related information could endanger the person.
__________________________________________________________________________________________
SECTION A: Covered individual requesting confidential communication:
Name: ____________________________________________
Member I.D.: ___________________
Birth Date: ______________________ Relationship to Primary Insured or Subscriber: __________________
Current Address: ___________________________________________________________________________
SECTION B: To the covered individual – please read the following and complete the information requested.
You have the right to make a reasonable request that you receive communications of claim-related information
from us by alternative means or at alternative locations if disclosing this information could endanger you.
“Claim-related information” means all claim or billing information relating specifically to you, including your
name, address, any services received, and the names and addresses of the service providers (such as your doctor).
I, _______________________________, request that The Hartford send communications of claim-related
information to me by the following alternative means or at the following alternative locations because disclosing
the claim-related information could endanger me:
In care of: _________________________________________________________________________________
(If you are using someone else’s address, then enter his or her name here.)
Alternative Address: ________________________________________________________________________
Alternative Phone Number: ____________________
Alternative Email Address: _____________________
Signature: _________________________________
Date: ________________
SECTION C: Parents, Guardians, or Legal Representatives
If the covered individual is a child younger than 18-years-old and the person making this request is the child’s
parent or guardian, then please provide:
Parent or Guardian’s Name: ________________________ Relationship to Covered Individual: ____________
If a legal representative, such as an attorney, is making this request on behalf of the covered individual, then
please provide:
Legal Representative’s Name: ______________________ Relationship to Covered Individual: ____________
Organization or Firm Name: __________________________________________________________________
Business Address: __________________________________________________________________________
Business Phone Number: _______________________
Business E-mail Address: _____________________
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life
Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT.