For Cultural Group Association Leaders

Step 1: Get a Quote:

To obtain a quote for your Cultural Group Association, please provide the following information:

Cultural Group Association Census Form – Click Here to Download

Group Leader Contact Information Form – Click Here to Download

To complete the census form for a preliminary quote, online you will need three required pieces of information about each active member of your cultural association: full name, date of birth, and gender. You may enter approximate ages if dates of birth are not readily available. But be aware that if approximate ages are used to obtain rate quotes, those rates may change when your members actually apply for coverage and furnish the required dates of birth.

You may omit social security numbers at this early point on the Census Form.

Note: When your group moves to the next stage and decides to apply for coverage, you will need to fill out all fields in the Census.

To submit the Census

To protect the data, please do not email us your census form with social security numbers on it. Please send us your completed Census Form via mail or fax:

  • Fax: Cultural Group Benefits Fax Number: 651.739.3265
  • Mail: Cultural Group Benefits Company, 6701 Upper Afton Road, Woodbury, MN 55125

Premium Rates

Premium rates are established for each cultural group based on its composition (total number of active members, ratio of males to females and their ages.)

When will I receive my quote?

You will receive a quote within 2 business days of submitting the census form. The quote will include rates for each benefit amount: $10,000, $15,000, $20,000, and $25,000.

Step 2: Apply

After your group has completed the Census form and submitted it to Cultural Group Benefits, you will receive a customized quote. You can take the following steps to move forward and enroll for the Group Term Life Insurance Plan.

To apply for Group Term Life Insurance coverage, your group must follow a two-step process.

Step 1: Group Application

Please return the following three forms to Cultural Group Benefits:

  • Acknowledgement Page. A group leader (President, or other designated leader) signs the Acknowledgement Page, which was included in your quote.
    On this page, you include your:

    1. official group name,
    2. your requested effective date,
    3. your requested premium frequency mode: quarterly, semi-annual, annual.
    4. your selected benefit levels (first year and second-year levels),
    5. and indicate whether or not your group selected to have an optional child rider on your policy.
  • Participation Agreement. Group leader signs the Participation Agreement, which was included in your Quote
  • Group By-laws. Group submits their Group By-laws to Cultural Group Benefits


Step 2: Group Member Enrollment

  • Once you have completed Step 1, the group leader (or designated insurance administrator) will receive from Cultural Group Benefits Member Term Life Insurance Enrollment Form. This Member Enrollment Form has been customized for the choices your group has made in terms of plan design.
  • The group leader must distribute the enrollment form to all the active members. Active members who wish to enroll must fill out the entire form and submit their premium payment to the group leader. PLEASE BE SURE ENROLLMENT FORM IS 100% COMPLETE!
  • The group leader will then submit all the enrollment forms and the first premium payments to Cultural Group Benefits. Enrollment forms and first premium payments must be received by Cultural Group Benefits before the effective date of the plan.


Underwritten by Hartford Life and Accident Insurance Company, Hartford, CT 06155.

Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

AGL-1942

Not available in all states.

The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company.

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