Fill - Free fillable EVIDENCE OF INSURABILITY FORM Life Insurance Company of (Jordan School District) PDF form

EVIDENCE OF INSURABILITY FORM

TL-009320

Life Insurance Company of North America (LINA)

a Cigna Company (herein called the Insurance Company)

For info and customer service call

• The applicant must sign and date this form.

• This form cannot be considered unless received within 30 days of the date it is dated.

Important: Please enter all dates in mm/dd/yyyy format.

Employer Use: (Mandatory Data Needed) In order to process this form, the employer must complete this information.

Employer: Policy:

Class: Location: Date of Hire:

nnual Salar

: Verified By:

Reason for Request: (i.e. New Hire, Late Entrant, Initial/Ongoing Enrollment, etc.)

VOLUNTARY COVERAGE EMPLOYEE AMOUNT SPOUSE* AMOUNT

1. Enter Requested Coverage Amount (Total)

2. Enter Current Coverage including guarantee issue (enter zero if no current coverage)

3. Subtract Line #2 from Line # 1, this is the amount subject to Underwriting

Complete the employee and spouse information in this section if you (i.e., the Employee) or your spouse* are applying for Life Insurance that is greater

than the guaranteed amount or are applying for Life Insurance more than 31 days after you were eligible for the insurance.

Height and Weight Information

Employee Height ___ft.___in. Weight ______lbs. Spouse* Height ___ft.___in. Weight ______lbs.

PHYSICIAN SECTION

Employee Physician Name Phone Number

Street Address City State Zip

Spouse*: Physician Name Phone Number

Street Address City State Zip

EMPLOYEE SECTION

Employee Name (first, middle, last) Social Security #

Address City State Zip

Phone ID # Birthdate Gender:  M  F

COMPLETE IF ELECTING SPOUSE* COVERAGE

I am currently married and my date of marriage is: –or– I currently have an eligible Domestic Partner

Spouse* Name: (first, middle, last) Social Security #

Phone Birthdate Gender:  M  F

IMPORTANT

Please complete each section that follows.

Read the Agreements and Authorization. Sign and date the form in the space provided.

PO Box 20310

Lehigh Valley, PA 18003

1-866-607-2360

Return form to: Cigna address above, Fax 1-800-440-0856, Email: bethlehemmail@cigna.com

Jordan School District

FLX-960159

Name Social Security #_________________________________________

TL-009320

SECTION B: Please indicate your answers for each question in this section by checking the Yes or No box for the question.

1. Within the last 5 years has the proposed insured:

Employee Spouse*

Yes No Yes No

A. Had a Driving While Intoxicated (DWI), Driving Under the Influence (DUI) or Operating Under the Influence (OUI)

conviction?

   

B. Smoked cigarettes:

   

1. For how many years has the proposed insured smoked?

2. Approximately how many cigarettes are, or were, smoked on average per day?

3. If cigarette smoking has been discontinued, when (month and year) did the proposed insured quit smoking?

C. Used any controlled or illegal drug or other substance?

   

D. Been seen for, or been advised to have sought treatment for, observation and/or consultation for surgery, medical

examination, and/or tests, such as blood, urine, X-rays, electrocardiograms, scans, biopsies, or any medical tests/exams

not listed here or above, other than normal routine physical exams?

   

E. Used any medication prescribed by a physician or other medical practitioner, or used any form of alternative and

complementary medical treatment or remedy, including herbs or acupuncture?

   

F. Been seen, sought treatment for, consulted, advised they had and/or received any medical advice from a health care

practitioner for any disease, disorder and/or medical impairment not listed above?

   

If you answered "Yes" to any questions above, please provide details in the table below.

Use the space below to explain "Yes" answers. If more space is needed, use a new pa

e. Si

n and date it. Attach it to this form.

Name of Employee, Spouse* Medical Condition Date Occurred Duration/Treatment Received Current Status

Section A: Please indicate your answers for each question in this section by checking the Yes or No box for the question.

1. Within the last 5 years has the proposed insured been diagnosed with any of the conditions, told by a medical

professional he/she has or may have any of the conditions, or been treated by a medical professional for any of the

conditions:

Employee Spouse*

Yes No Yes No

A. High blood pressure, heart attack, chest pain or Angina, a heart murmur, poor circulation or any other condition affecting

the heart or circulatory system?

   

B. Diabetes, glandular condition, Hepatitis, or any condition affecting the esophagus, stomach, intestines, liver or pancreas?

   

C. Asthma, Chronic Bronchitis, Emphysema, or any other condition affecting the lungs or respiratory tract?

   

D. Any condition affecting the kidneys, urinary tract, prostate gland or reproductive system?

   

E. HIV infection, AIDS, or any other condition affecting the immune system or lymph nodes?

   

F. Stroke, Transient Ischemic Attack (TIA), Alzheimer’s disease, paralysis, Epilepsy, fainting, seizures, headaches, or other

condition affecting the nervous system?

   

G. Anemia or any other condition affecting the blood, Lupus, Arthritis, deformity or loss of limb?

   

H. Anxiety, Depression, Bipolar Disorder, or any other mental disorder or condition?

   

I. Cancer, Tumor, Leukemia, Hodgkin’s Disease, Polyps or Mole?

   

J. Alcohol or drug abuse or dependency?

   

Name Social Security #_________________________________________

TL-009320 (DE-T)

AGREEMENTS AND AUTHORIZATION

To the best of my knowledge and belief all written, telephonic and electronic information I gave is true and complete. I understand that my insurance will

not go into effect unless I am actively at work on the effective date. I also understand that coverage for each of my dependents will not go into effect

unless the person is not confined in a hospital or institution, or receiving certain medical treatment. The conditions for the requested insurance to be

effective are described in the policy and certificate. The approval of this request by the Insurance Company is one of those conditions. I understand and

agree that:

(1)

This request will be a part of the policy that provides the insurance.

(2)

I may need to provide more medical info.

(3)

I may need to take medical tests and report the results to the Insurance Company.

(4)

I must report any change in my health that happens before the insurance is effective.

(5)

Requested insurance will not be effective for a person if the person does not meet the underwriting requirements on the date insurance is to be

effective.

Authorization. I permit any hospital, clinic, health care practitioner, pharmacy, benefit manager, employer, insurance company, the Medical Information

Bureau (MIB) or any other person or organization having info about the health, medical history, physical or mental condition, diagnosis or treatment,

employment or income, or motor vehicle driving record, to disclose to the Insurance Company or its authorized agent, any such info, for the purpose of

underwriting this application for insurance or administering any claim under any insurance which is approved. This authorization is valid for 30 months

from the date below. I accept that a copy of this Authorization is as valid as the original.

I understand that I and/or my authorized agent have the right to receive a copy of this authorization upon request.

I understand that the info will be used to assess my request for insurance.

I may revoke this authorization at any time in writing. Any such revocation will not: (1) change any action taken in reliance on the Authorization; and (2)

change the Insurance Company’s right to use the Authorization for contest of a claim or policy in accordance with applicable law.

I understand that info provided pursuant to this authorization may be disclosed by the recipient and is no longer subject to the protections of the Health

Insurance Portability and Accountability Act (HIPAA). (The Insurance Companies are subject to the Gramm-Leach-Bliley act and state privacy laws. They

do not disclose protected information except as permitted by those laws.)

*For purposes of this form, wherever the term Spouse appears, it shall also include Domestic Partner registered under any state which legally recognizes

Domestic Partnerships or Civil Unions.

Caution:

Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or

statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material

thereto, commits a fraudulent insurance act.

Sign Here

Employee's Signature Month/Day/Year Spouse's Signature* Month/Day/Year

(If applying for insurance for your spouse)

Notice:

Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties

without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about

the insurance company’s privacy practices is available upon request.

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EVIDENCE OF INSURABILITY FORM Life Insurance Company of (Jordan School District)

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