Fillable EvidEncE of insurability (ca) (Chaffey College)

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EvidEncE of insurability (ca) (Chaffey College)

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RL-EOI-2011-CA Page 1 of 3 - Incomplete without all pages. Order #162262 CA 05/01/2014
Group Number
Account Number
Employer Name
Are you completing this form due to a Family Status Change (Marriage, Divorce, Birth, Adoption, etc.)?
Yes No
C. SpouSe InformatIon
Coverage Type
(A)
Total Amount Desired
(B)
Current Amount
(C)
Guaranteed Issue Amount
(A) – (B) – (C)
= Amount
To Be Underwritten
Employee Supplemental Life
$ $ $ $
Spouse Supplemental Life
$ $ $ $
Children Supplemental Life (per child)
$ $ $ $
Hire Date Salary $ Occupation
Employee Name
(First, MI, Last)
Gender: Male Female
Birth Date SSN Personal Email Address
Birth Date SSN Personal Email Address
Home Phone ( ) Cell Phone ( )
Primary Health Practitioner Practitioner Phone ( )
Primary Health Practitioner Practitioner Phone ( )
Same Primary Health Practitioner as Employee (See information above.)
Address
City
State ZIP
B. InSuranCe DetaIlS (Complete this table based only on the coverage you have through this plan.)
Practitioner Address City State ZIP
Spouse Name
(First, MI, Last)
Gender: Male Female
Home Phone ( ) Cell Phone ( )
Practitioner Address City
State
ZIP
D. ChIlD InformatIon (Availability of Child coverage is dependent on plan rules and may also be dependent on approved
employee coverage. If more than 3 children, list information on additional sheet.)
Name
(First, MI, Last)
Birth Date Gender Relationship
Male Female
Male Female
Male Female
Dependent Children Health Questions (Answer these questions only if applying for dependent child(ren) coverage.)
1. Within the past 5 years, have any dependent children been treated for or diagnosed with a mental or nervous disorder (excluding
ADHD), diabetes, heart disorder, cancer, asthma (requiring hospitalization within the last 2 years), or chemical abuse? . . . . . . . . Yes No
2. Do any dependent children have cerebral palsy, cystic fibrosis, muscular dystrophy, developmental disorder (including Autism and
Down’s Syndrome)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
For each “Yes” answer, provide name(s) of child(ren) and details.
Use this form to apply for insurance coverage in addition to coverage you may already have through this plan.
a. employee InformatIon
Structure I Structure II Structure III Structure IV
EvidEncE of insurability (ca)
ReliaStar Life Insurance Company, Minneapolis, MN
A member of the Voya family of companies
PO Box 20, Mail Stop 4-S, Minneapolis, MN 55440
Phone: 612.342.7262 Fax: 612.467.8721
RESET FORM
662003
19
California Schools Employee Benefits Assoc
Location
Chaffey Comm Coll
Option 2
Option 3
Option 4
0000000000
RL-EOI-2011-CA Page 2 of 3 - Incomplete without all pages. Order #162262 CA 05/01/2014
e. employee anD SpouSe health QueStIonS (Must be answered for coverage that is not Guaranteed Issue.)
Question
Number
Applicant
Description of Condition
Date
Condition
Began
Description of
Treatment Received
Fully
Recovered?
Health Practitioner Name, Full
Address (Street, City, State, ZIP),
Phone
EE
SP
Yes
No
EE
SP
Yes
No
EE
SP
Yes
No
EE
SP
Yes
No
For every “Yes” answer, to any question in the previous section, give details below. Please attach a separate sheet if additional space is needed.
Employee Name SSN (Last 4 digits only.)
Employee (EE)
Yes No
Spouse (SP)
Yes No
- N/A -
1. Within the last 5 years have you been treated for or been diagnosed by a member of the medical profession or health
practitioner as having AIDS (Acquired Immunodeciency Syndrome)?
2. Within the last 5 years have you been treated for, any of the following: insulin dependent diabetes, heart attack,
coronary bypass/angioplasty, heart valve repair/replacement, stroke, metastatic cancer, emphysema or been an organ
transplant recipient?
3. Employee: Height ft. in. Weight lbs. Spouse: Height ft. in. Weight lbs.
4. In the past 5 years have you been diagnosed or treated by a health practitioner, or taken medication for any of the following:
a. Any disease or abnormality of the heart or blood vessels (excluding controlled high blood pressure), or any heart
rhythm abnormality?
b. Any disease of the lung (excluding asthma), liver (excluding hepatitis A), pancreas or intestine?
c. Non-insulin dependent diabetes, impaired glucose tolerance, or pre-diabetes?
d.
Cancer or tumor, rheumatoid arthritis, connective tissue disease, neurological disease (excluding headaches),
autoimmune disease or any disease of the blood cells or serum including, but not limited to, anemia, polycythemia, or
bleeding or clotting disorder?
e. Depression, psychosis, suicide attempt, drug or alcohol abuse or addiction?
f. Polycystic kidney disease or kidney failure?
5. Within the last 5 years have you been diagnosed or treated by a physician or other health practitioner for:
a. Chest pain, heart trouble or circulatory condition?
b. Anemia or leukemia?
c. Sleep apnea, asthma or other respiratory disease?
d. Colitis, Crohn’s disease, ulcerative colitis or any other intestinal disease?
e. Stomach disease?
f. Brain or seizure disorder?
g. Mental or nervous disorder?
h. Arthritis, paralysis or any muscle weakness impacting your ability to perform daily activities?
i. Abnormal urine specimen or urinary tract disorder?
j. Prostate or other reproductive organ disorder?
6. Are you pregnant? Due Date Pre-pregnancy weight lbs
7. Are you currently taking any medication prescribed or provided by a physician or other health practitioner for any
disorder, condition, or disease not shown above?
8. Within the last 5 years have you received medical treatment or counseling for the use of alcohol or prescribed or non-
prescribed drugs, or been advised by a health practitioner to discontinue the use of such substances?
9. In the past 2 years have you had any medical issues for which you have not yet consulted a health practitioner, or are
any medical, surgical or diagnostic procedures recommended or contemplated?
If applying for disability income coverage, please complete this additional question:
Complete for EE and SP.
---
>
RL-EOI-2011-CA Page 3 of 3 - Incomplete without all pages. Order #162262 CA 05/01/2014
f. authorIzatIon anD aCKnoWleDGment (Please read and sign below)
For underwriting and claim purposes, I give my permission to any physician or other medical practitioner, hospital, clinic, rehabilitation facility, insurance
or reinsuring company, MIB, Inc. (MIB), any consumer reporting agency to give ReliaStar Life Insurance Company (ReliaStar Life) or its authorized
representative (including any consumer reporting agency) acting on its behalf ALL INFORMATION on my behalf (except as limited below). This includes but
may not be limited to: (a) findings on medical care, psychiatric or psychological care or examination, or surgery, as they apply to me; and (b) any non-medical
information as it applies to me. I give my permission to ReliaStar Life to obtain consumer or investigative consumer reports about me.
I give my permission to ReliaStar Life and other insurance companies affiliated with ReliaStar Life to obtain any and all medical record information for
the purposes described in this form. I know that my medical records, including any alcohol or drug abuse information, may be protected by Federal
Regulations–42 CFR Part 2. I may revoke this permission as it applies to any information protected by 42 CFR Part 2 at any time, but not to the extent
action has been taken in reliance on it. I specifically consent to the re-disclosure of medical record information as set forth in this form. In connection with
any application for life insurance, or other insurance transaction that I may have with ReliaStar Life or any of its affiliated companies, I understand that I may
request that this information not be communicated to companies affiliated with ReliaStar Life.
I authorize ReliaStar Life, or its reinsurers, to disclose personal health information about me to MIB, Inc. in the form of a brief coded report for participation
in MIB’s fraud prevention and detection programs.
I understand that my further written consent will be required before any information described above is given, sold, transferred, or, in any way, relayed to
another party not before specified. My further consent must be provided on a form that states the new use of the information or why another party needs it.
I know that I have a right to receive a copy of this form. I certify that I have, will print, or will otherwise have access to a copy of all pages of this Evidence
Form to keep for my records. A photocopy of this form will be as valid as the original. This form will be valid for 24 months from the latest date shown below.
I acknowledge that I have been given ReliaStar Life’s: Consumer Privacy Notice and Insurance Information Practices Notice.
Employee Signature Date
Spouse Signature Date
IMPORTANT! Please carefully read the next section. Then sign and date below.
I declare that all of the statements and answers, as they pertain to me and to my child(ren), if applicable, on all pages of this Evidence Form are complete
and true to the best of my knowledge and belief.
I realize that any misrepresentation or omission regarding the presence of any pre-existing impairments and/or diseases may result in the
requested coverage or benefits provided by such coverage being contested. I understand that any claim incurred prior to the approval of this
Evidence Form by ReliaStar Life Insurance Company’s Home Office will not be valid.
Submit your EOI form directly to the insurer for fast and confidential handling via one of
the methods below:
Fax to: 1-612-467-8721
Or
Mail to: ReliaStar Life Insurance Company, PO Box 20, Mail Stop 4-S, Minneapolis, MN 55440
Employee Name SSN (Last 4 digits only.)
47316c Page 1 of 1 Order #116249 05/01/2014
We are pleased to provide you with information regarding your application or claim. This information is provided to you in accordance with legislation
enacted in your state. You may also receive other privacy notices from us or from our affiliated companies. Please keep this notice and a copy of the
completed application or claim form for your records.
Our Underwriting Procedures
For certain types of coverage, we underwrite your request to determine if you are eligible for the coverage you requested. We review all of the information
in the application, and, if necessary, confirm or add to this information in the ways described in this notice. In the event of an adverse underwriting decision,
we will provide you with the specific reason for the decision in writing.
Privacy and Information Practices
Collecting Information
Your application or claim form is our main source of information. But we may:
- Ask you to have a physical exam, an EKG and/or a blood profile, etc.
- Ask physicians, hospitals, or other health care providers to confirm or add to the information you have given us. The types of information we may ask for
are described on the authorization form you will be asked to sign. If you want a copy of this form, it will be given to you for your records.
- Obtain information from MIB, Inc., formerly known as the Medical Information Bureau. See “Notice Regarding MIB, Inc.” below.
- Seek information from other companies you have applied to for insurance.
- Ask you for additional information through use of a written request.
Notice Regarding Consumer Reports
Insurance companies commonly ask an outside source to verify and add to the information given in an application. Consumer reports are used to help us
decide if you are eligible for the insurance you have applied for. The report deals with your mode of living, character, general reputation, and such personal
items as your health, job, and finances. It may include information on the following: your marital status, past and present employment record, job duties,
driving record, avocation, health history, use of alcohol and drugs, and hazardous sports activities. The agency may get information in these ways: from public
records, and by contacting you, members of your family, business associates and employers, financial sources, friends, or others you know. This information
will not be used to determine your sexual orientation. You can request that the agency interview you in connection with the preparation of the report. If the
report affects your application as requested, we will notify you and provide you with the name and address of the reporting firm.
We use the report only to be sure that each application is evaluated on a fair basis. We will not reveal any of the information we obtain to your friends
or associates. We may reveal the information we obtain to other companies or entities affiliated with us. The information may be kept by the consumer
reporting agency; it may also later be given to others who have a legitimate need for these reports. It will be given only to the extent permitted by these
laws: the Federal Fair Credit Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996; your state’s Fair Credit Reporting Act, if any;
or your state’s Insurance Information and Privacy Protection Act, if any. If you wish, we will send you the name, address and phone number of any agency
we ask to prepare a consumer report about you. The agency will give you a copy of the report if you ask for one and give proper identification.
Information Use
We will use the information only for business purposes arising from the relationship you have with us.
Information Maintenance and Disclosure
We treat the information we have about you as confidential. The authorization form that you have been asked to complete will permit us to send the
information to our affiliates and to MIB, our reinsurers, employees, contractors, or other organizations that process transactions concerning coverage you
have with us or our affiliates, and to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may
be submitted. In certain circumstances, the information we have about you may be disclosed to third parties without your specific permission.
Access to Information
If you request it in writing, we will send you a copy of the relevant information we obtain about you in connection with your request for coverage or an
adverse underwriting decision. Medical information, however, will only be disclosed through the attending licensed physician unless state law provides
otherwise. If you feel that any of the information in our file is not correct or is incomplete, we will review it. If we agree with you, we will make the corrections.
If we do not agree with you, you may file a short statement of dispute with us. Your statement will be included any time we disclose this information to
anyone. We will not send you information we collect in expectation of or in connection with any claim or civil or criminal proceeding.
Notice Regarding MIB, Inc.
We or our reinsurers may make brief reports to MIB. The reports will include the factors that affect the insurability of any person for whom coverage is being
requested. MIB is a nonprofit organization of life insurance companies. It operates an information exchange for its members. If you apply to some other
member company for life or health coverage, or send in a claim for benefits, MIB may supply that company with any information in its file. If you ask, MIB
will arrange to disclose to you the information it has about you in its file. If you question the accuracy of the information in MIB’s file, you may contact MIB
and ask them to correct it as provided in the Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree,
MA 02184-8734. MIB’s phone number is 866-692-6901 (TTY 866 346-3642). We may also release information in our files to other life insurance companies
to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.
CONSUMER PRIVACY NOTICE AND
INSURANCE INFORMATION PRACTICES NOTICE
ReliaStar Life Insurance Company, Minneapolis, MN
ReliaStar Life Insurance Company of New York, Woodbury, NY
Members of the Voya family of companies
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Completed 3 September 2020

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