HOOPER HOLMES INC - FORM S-1 - EX-99.6 - EXHIBIT 99.6 - November 12, 2015

Attached files

file filename
EX-99.1 - EXHIBIT 99.1 - HOOPER HOLMES INCexhibit991s12015.htm
EX-24.0 - EXHIBIT 24.0 - HOOPER HOLMES INCexhibit24s12015.htm
EX-4.2 - EXHIBIT 4.2 - HOOPER HOLMES INCexhibit42s12015.htm
EX-10.13 - EXHIBIT 10.13 - HOOPER HOLMES INCexhibit1013s12015.htm
EX-99.2 - EXHIBIT 99.2 - HOOPER HOLMES INCexhibit992s12015.htm
EX-99.7 - EXHIBIT 99.7 - HOOPER HOLMES INCexhibit997s12015.htm
EX-99.5 - EXHIBIT 99.5 - HOOPER HOLMES INCexhibit995s12015.htm
EX-99.4 - EXHIBIT 99.4 - HOOPER HOLMES INCexhibit994s12015.htm
EX-99.8 - EXHIBIT 99.8 - HOOPER HOLMES INCexhibit998s12015.htm
EX-99.3 - EXHIBIT 99.3 - HOOPER HOLMES INCexhibit993s12015.htm
S-1 - S-1 - HOOPER HOLMES INChhforms-1rightsoffering17xc.htm
EX-23.1 - EXHIBIT 23.1 - HOOPER HOLMES INCexhibit231s12015.htm




Exhibit 99.6

FORM OF NOMINEE HOLDER ELECTION FORM

The undersigned, a bank, broker, trustee, depositary or other nominee of non-transferable subscription rights (the “Rights”) to purchase shares of common stock, par value $0.04 per share (the “Common Stock”), of Hooper Holmes, Inc. (the “Company”), pursuant to the rights offering (the “Rights Offering”) described and provided for in the Company’s prospectus dated [*], 2015 (the “Prospectus”), hereby certifies to the Company and to Broadridge Financial Solutions, Inc., as subscription agent for the Rights Offering (the “Subscription Agent”), that (1) the undersigned has exercised, on behalf of the beneficial owners thereof (which may include the undersigned), on the terms and subject to the conditions set forth in the Prospectus, the number of Rights specified below to purchase the number of shares of Common Stock specified below pursuant to the Basic Subscription Right (as defined in the Prospectus) and, on behalf of beneficial owners of Rights who have subscribed for the purchase of additional shares of Common Stock pursuant to the Over-Subscription Privilege (as defined in the Prospectus), the number of shares specified below pursuant to the Over-Subscription Privilege, listing separately below each such exercised Basic Subscription Right and the corresponding Over-Subscription Privilege (without identifying any such beneficial owner by name), and (2) to the extent a beneficial owner has elected to subscribe for shares pursuant to the Over-Subscription Privilege, each such beneficial owner’s Basic Subscription Right has been timely exercised in full.

 
 
 
 
 
 
 
 

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[Certification continues on the following page]
 

 
Provide the following information, if applicable:

 
 
 
 
Name of Nominee Holder
 
DTC Participant Number
 
 
 
 
 
 
By:
 
 
 
 
 
 
 
DTC Subscription Confirmation Numbers
 
Name:
 
 
 
 
 
 
 
 
 
Title:
 
 
 
 
 
 
 
 
 
Phone Number:
 
 
 
 
 
 
 
 
 
Fax Number:
 
 
Dated
 
 
 
 
 
 
 
 
 
 
 
 



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