()
HAVE YOU GAINED OR LOST MORE YES – IF SO GAINED GIVE DETAILS
THAN 20 POUNDS IN THE LAST YEAR? NO LOST ___________ POUNDS BELOW.
Evidence of Insurability
FOR COMPANY USE ONLY
APPROVED: ______________
DATE: ___________________
Ev
This applicant is:
New Group
Addition to Existing Group
Change of Benets
Group No.: _________________________________
Application is made for:
Basic Life Amount: _______________________
Supplemental Life Amount:________________
Dependent Life Amount: __________________
Other: _________________________________
NAME OF APPLICANT IF DEPENDENT, RELATIONSHIP TO EMPLOYEE
ADDRESS STREET CITY STATE ZIP CODE PHONE NUMBER
DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NO. SEX
YOUR OCCUPATION EMPLOYER’S NAME
HEIGHT WEIGHT
FULL NAME OF YOUR REGULAR PHYSICIAN
FULL STREET ADDRESS OF YOUR REGULAR PHYSICIAN STREET CITY STATE ZIP CODE
DATE AND REASON LAST CONSULTED
1. If employed, are you actively at work at least 20 hours a week? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
2. During the last ve years, have you been absent from work more than ve consecutive
working days because of illness or injury? If “YES”, give details below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
3. Are you now under regular medical observation or taking medical treatment?
If “YES”, give details below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
4. Within the last ve years, have you consulted a physician for any disease or injury,
or have you been advised to have any surgical operation or diagnostic tests?
If “YES”, give details below. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
5. To the best of your knowledge have you had or been told you had an
Immune Decient Disorder (AIDS), or the AIDS Related Complex (ARC),
or test results indicating exposure to the AIDS Virus? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO
6. Please check either “YES” or “NO” if you ever had or have been told that you had any of the following.
If “YES”, give details below.
YESNOYES NO YESNO
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . Diabetes or Albumin or Sugar in the Urine . . . . . . Lung Disorder . . . . . . . . . . . . . . . . . . . . . . . . .
Rheumatic Fever . . . . . . . . . . . . . . . . . . . . . . . . . . Disorder of the Stomach or Intestines or Liver. . . Kidney Disorder . . . . . . . . . . . . . . . . . . . . . . .
Heart Murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nervous Disorder or Epilepsy . . . . . . . . . . . . . . . . . . . Back Disorder . . . . . . . . . . . . . . . . . . . . . . . . .
Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paralysis or Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sexually Transmitted Disease. . . . . . . . . . . . . . Cancer or Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONDITION DATE REMAINING EFFECTS PHYSICIAN’S FULL NAME AND ADDRESS
I have read the answers and statements on this application and agree that the above answers are complete and true to the best of my knowledge and belief.
I acknowledge receipt and understanding of “Notice of Exchange of Information” explained below.
I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, the Medical Information Bureau or other
organization, institution or person, that has any records or knowledge of me or my health to give Anthem Blue Cross Life and Health Insurance Company or its reinsurers any
A photographic copy of this authorization shall be as valid as the original.
CUT OFF - FOR APPLICANT’S REFERENCE
NOTICE OF EXCHANGE OF INFORMATION
Thank you for enrolling for Group Insurance with Anthem Blue Cross Life and Health Insurance Company. As part of the normal procedure of processing the group policy, information concerning proposed insureds may be obtained relative to
each person’s insurability.
Information regarding your insurability will be treated as confidential. Anthem Blue Cross Life and Health Insurance Company or its reinsurers may, however, make a brief report thereon to the Medical information Bureau, a nonprofit
membership organization of life insurance companies which operates an information exchange on behalf of its members. If you aply to another Bureau member company for life or health insurance coverage or a claim for benefits is submitted
to such company, the Bureau, upon request. will supply such company with the information it may have in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of information in the
Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is Post Office Box 105, Essex Station , Boston,
Massachusetts 02112, telephone number (617) 426-3660.
SIGNATURE OF APPLICANT DATE
Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.
MCAFR2701B 2/08
such information
275233 Super Micro Computer, Inc.
Employee's Name (Last, First MI):
________________
Employee ID# ________
Employee's SSN #xxx-xx- ________
$50K (FT Employee Only-Auto Enrollment)
Employee Spouse / Domestic Partner (Non-Employee)
Employee's SSN: xxx-xx- __ __ __ __
Employee's Employer: Super Micro Computer, Inc.
