Applications are state-specific. Select the state you live in, which may not be the same as your employer. Once completed and signed, you can upload your form using the Upload Documentation button on the home page of the member enrollment portal.

Hartford EOI App – FL

Hartford EOI App – GA

Hartford EOI App – NJ

Hartford EOI App – NH

Hartford EOI App – NY

Hartford EOI App – VA

Hartford EOI App – AllOthers

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Toll Free: 800.258.9732
Local: 603.669.4771
Fax: 603.666.4477

Allegiant Care
51 Goffstown Road
P.O. Box 4604
Manchester, NH 03108

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