Fillable Evidence of Insurability Cover Sheet (Samford University)

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Evidence of Insurability Cover Sheet (Samford University)

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www.LincolnFinancial.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
Evidence of Insurability Cover Sheet
Please forward this cover sheet with your completed Evidence of Insurability form to
The Lincoln National Life Insurance Company at one of the following:
Mail – PO Box 2616 Omaha, NE 68103,
Fax – 877-573-6177 or Email – lfgenrollments@lfg.com
Group Name/Group ID:
Date:
Employee Class:
Employee Name:
Employee Billing Location:
Spouse Name:
Employee Sort Group:
Basic Coverage(s)
Current Amount of
Coverage
Additional Amount of
Coverage
Total Amount of
Coverage
Life
$
$
$
Dependent Life
$
$
$
STD
$
$
$
LTD
$
$
$
LTD with Critical Illness
$
$
$
Voluntary/Optional Employee
Life
$
$
$
Voluntary/Optional Employee
Life & AD&D
$
$
$
Voluntary/Optional Spouse
Life
$
$
$
Voluntary/Optional Spouse
Life & AD&D
$
$
$
Voluntary/Optional Short Term
Disability (STD)
$
$
$
Voluntary/Optional Long Term
Disability (LTD)
$
$
$
Critical Illness (Mark
Categories Below)
Enter Principal Sum for:
Heart Category
Cancer Category
Organ Category
Quality of Life Category
Employee $
Spouse $
Child $
Employee $
Spouse $
Child $
Employee $
Spouse $
Child $
Samford University, SAMFORDUNV-BL-713872
Class 1
GL4A 10 FL 0/201
The Lincoln National Life Insurance Company
A Stock Company Home Office Location: Fort Wayne, Indiana
Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616
Phone: (800) 423-2765 Fax: (877) 573-6177
EVIDENCE OF INSURABILITY INFORMATION
Please submit this form to The Lincoln National Life Insurance Company (herein referred to as "the Company"). No coverage for
which evidence of insurability is required will be effective until approved in writing by the Company.
Complete all blanks in ink and print clearly. Incomplete forms will cause consideration for coverage to be delayed.
SECTION 1. Group Information:
Group Name Group ID
Group Policy No(s). Billing Division/Location
SECTION 2. Employee Information: (Complete even if employee is not applying for coverage.)
First Name
Last Name Middle Initial
Social Security No. - - State of Birth Date of Birth / /
Annual Earnings $ Date of Hire/Rehire / /
Home Mailing Address:
(Street) (City) (State) (Zip)
Phone No(s): Home ( ) - Work ( ) - Best Time to Call AM/PM
Email Address: Home Work
Beneficiary (for Life or AD&D Insurance)
Relationship
SECTION 3. Spouse Information: (Complete only if applying for Dependent coverage.)
First Name
Last Name Middle Initial
Social Security No. - - State of Birth Date of Birth / /
Home Mailing Address (if different than above):
(Street) (City) (State) (Zip)
Phone No(s): Home ( ) - Work ( ) - Best Time to Call AM/PM
Email Address:
Home Work
SECTION 4. Plan(s) Applied for: (Only include the amount of coverage in excess of any existing amount or guaranteed issue
amount.)
Basic Coverage(s) Requested Basic
Coverage Amount
Optional/Voluntary Coverage(s) Requested
Optional/Voluntary
Coverage Amount
Life
$
Employee Life
$
Dependent Life
$
Employee Life & AD&D
$
STD
Spouse Life
$
LTD
Spouse Life & AD&D
$
LTD with Critical Illness
Short Term Disability (STD)
$
Long Term Disability (LTD)
$
Critical Illness (Mark Categories below) Enter Principal Sum for:
Heart Category
Cancer Category
Organ Category
Quality of Life Category
Employee $
Spouse $
Child $
Samford University
SAMFORDUNV-BL-713872
000400236837
GL4A 10 FL CONTINUED ON NEXT PAGE 0/201
STATEMENT OF HEALTH
SECTION 5. Medical Information - To be completed by applicants applying for ANY coverages.
Employee Applicant Gender: Male Female Height: Ft. In. Weight: lbs.
Spouse Applicant Gender: Male Female Height: Ft. In. Weight: lbs.
Employee Spouse
YES NO YES NO
In the past 12 months, have you smoked a cigarette, cigar or pipe, chewed tobacco or used tobacco
or nicotine in any form?
SECTION 6. Medical Information - To be completed if applying for LIFE or DISABILITY coverages.
Employee Spouse
YES NO YES NO
1. Within the past 7 years, have you ever been (a) diagnosed by a licensed member of the medical
profession with, or (b) received treatment from a licensed member of the medical profession for
a disorder listed below? (FOR DISORDERS ANSWERED YES, PLEASE PROVIDE
DETAILS IN SECTION 7.)
a. Heart or circulatory disorder; liver or kidney disorder; lung or respiratory disorder; mental
or nervous disorder; alcoholism, drug or substance abuse; diabetes, cancer, tumor, epilepsy,
hepatitis or stroke?
b. High blood pressure? If answered YES, please provide last reading and date of reading:
BP Reading (Employee)
Date
BP Reading (Spouse)
Date
2. Within the past 7 years, have you:
a. tested positive for exposure to the HIV (Human Immunodeficiency Virus) infection or been
diagnosed as having (AIDS) or AIDS Related Complex (ARC), caused by the HIV
infection or other sickness or condition derived from such infection?
b. been diagnosed as having Hepatitis, any disorder of the immune system or any sexually
transmitted disease other than AIDS or ARC?
(FOR CONDITIONS ANSWERED YES, EXCEPT FOR QUESTION 2.a, PLEASE
PROVIDE DETAILS IN SECTION 7.)
3. Within the past 5 years, have you been diagnosed by a licensed member of the medical
profession with a physical disorder not listed above? (IF ANSWERED YES, PLEASE
PROVIDE DETAILS IN SECTION 7.)
4. Are you currently under observation by or receiving treatment from a licensed member of the
medical profession, or taking medication?
(IF ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)
5. If applying for DISABILITY coverage, please complete these additional questions.
a. Are you currently pregnant?
b. Within the past 5 years, have you been diagnosed or treated by a licensed member of the
medical profession for:
i. Disorder of the back, neck, or spine?
ii. Osteoarthritis, Rheumatoid Arthritis, or degenerative joint disease?
iii. Knee Disorder, Injury or Surgery?
(FOR CONDITIONS ANSWERED YES, PLEASE PROVIDE DETAILS IN SECTION 7.)
GL4A 10 FL CONTINUED ON NEXT PAGE 0/201
SECTION 7. Provide details for any questions answered YES in SECTION 6. (Attach additional sheet, if needed.)
Question
Number
Applicant Name Condition/Treatment/Medication Date of
Diagnosis
Date of Last
Symptom
Current
Status or
Condition
Attending
Physician's Name,
Address, and
Phone Number
SECTION 8. Medical Information - To be completed if applying for CRITICAL ILLNESS coverage.
Employee Spouse
YES NO YES NO
1. Within the past 7 years, has anyone applying for coverage been diagnosed or received treatment
by a licensed member of the medical profession for Systemic Lupus, Type I or II Diabetes,
sarcoidosis, or tested positive for exposure to the HIV (Human Immunodeficiency Virus)
infection or been diagnosed as having (AIDS) or AIDS Related Complex (ARC), caused by the
HIV infection or other sickness or condition derived from such infection?
If applying for the Heart Category, please complete the questions below.
2. Within the past 7 years, has anyone applying for coverage been diagnosed or received treatment
by a licensed member of the medical profession for a Pacemaker, any type of fibrillation,
coronary artery disease, atherectomy or any type of heart surgery, heart attack, congestive heart
failure, cardiomyopathy, stroke, transient ischemic attack, congenital heart disease, chronic
anticoagulation therapy?
3. Is anyone applying for coverage currently taking three or more high blood pressure (HBP)
medications or had HBP medications changed or increased within the past six months?
If applying for the Cancer Category, please complete the question below.
4. Within the past 7 years, has anyone applying for coverage been diagnosed or received treatment
by a licensed member of the medical profession for internal cancer, melanoma, bone marrow or
stem cell transplant?
If applying for the Organ Category, please complete the question below.
5. Within the past 7 years, has anyone applying for coverage been diagnosed or received treatment
by a licensed member of the medical profession for Cystic fibrosis, renal hypertension or any
kidney disease or disorder (not including stones), chronic obstructive pulmonary disease,
emphysema, pulmonary fibrosis, Hepatitis or liver disease or disorder (not including Hepatitis A),
cirrhosis of the liver, any organ transplant, or donor?
If applying for the Quality of Life Category, please complete the question below.
6. Within the past 7 years, has anyone applying for coverage been diagnosed or received treatment
by a licensed member of the medical profession for glaucoma or retinitis pigmentosa?
FRAUD WARNING. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE
ANY INSURER, FILES A STATEMENT OF CLAIM, OR AN APPLICATION CONTAINING ANY FALSE,
INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
GL4A 10 FL PLEASE COMPLETE THE ATTACHED AUTHORIZATION 0/201
I HEREBY:
1. request the coverage for which I am (or may become) or my Spouse is (or may become) eligible under group policies issued by
The Lincoln National Life Insurance Company;
2. authorize any required deductions from my earnings;
3. name the above beneficiary to receive any benefits payable in the event of my death;
4. represent to the best of my knowledge and belief that the above Statement of Health is true and complete, and that each item
answered yes is fully disclosed;
5. represent that if the above Statement of Health has been completed to obtain coverage for my Spouse, I have discussed and
reviewed with my Spouse the responses and information supplied on behalf of my Spouse in the Statement of Health, and to the
best of our knowledge and belief, the Spouse portion of the Statement of Health is true and complete, and each item answered yes
is fully disclosed; and
6. acknowledge that I have read the FRAUD WARNING.
I understand that for continued eligibility I must remain an active employee working at least the minimum hours or otherwise
continue coverage as outlined in the contract. The attached AUTHORIZATION has been completed and signed by the
employee.
Signature of (Employee) Applicant:
Date:
Signature of (Spouse) Applicant: Date:
Licensed Resident Agent (signature)
Group Insurance Service Office Use
Self Bill List Bill
Approved Declined
Licensed Resident Agent (typed, printed or stamped)
EFFECTIVE DATE
License ID#
GL4A 14 AUTH
The Lincoln National Life Insurance Company
A Stock Company Home Office Location: Fort Wayne, Indiana
Group Insurance Service Office: P.O. Box 2616, Omaha, NE 68103-2616
Phone: (800) 423-2765 Fax: (877) 573-6177
AUTHORIZATION: I (the undersigned) authorize any physician, medical professional, medical facility, pharmacy benefit
manager, insurer, reinsurer, consumer reporting agency or MIB, Inc. ("MIB") to release information from the records of:
1. Applicant/Patient Name:
(Last) (First) (Middle)
Date of Birth: Social Security Number:
This Authorization covers any periods of medical treatment during the last seven years.
2. Information to be released: My complete medical records including:
information about the diagnosis, treatment or prognosis of my medical condition (including referral documents from other
facilities); and
prescription drug records and related information maintained by physicians, pharmacy benefit managers, and other sources.
3. Information is to be released to: EMSI (Examination Management Services Incorporated), The Lincoln National Life Insurance
Company or its reinsurers.
4. I understand that the purpose of disclosing this information is to evaluate my application for insurance. The Company will use the
information obtained with this Authorization to determine eligibility for insurance; and will only release such information:
to reinsurance companies, the MIB or providers of a business or legal service concerned with my application; and
as otherwise may be required by law or may be further authorized by me.
5. I authorize The Lincoln National Life Insurance Company, or its reinsurers, to disclose Protected Health Information or 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 further understand that refusal to sign this Authorization may result in denial of eligibility for this insurance coverage.
6. I understand the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and
may no longer be protected by federal law, however, the Company contractually requires the recipient to protect the information.
7. I understand that I may revoke this Authorization in writing at any time, except to the extent: 1) the Company has taken action in
reliance on this Authorization; or 2) the Company is using this Authorization in connection with a contestable claim under my
coverage with the Company. If written revocation is not received, this Authorization will be considered valid for a period of time
not to exceed 24 months from the date of signing. To initiate revocation of this Authorization, direct all correspondence to the
Company at the above address.
8. A photocopy of this Authorization is to be considered as valid as the original.
9. I acknowledge that I have received the attached Notice of Information Practices.
10. I understand that I am entitled to receive a copy of this Authorization.
Signature of Applicant: Date:
GL4A 14 MIB NOTICE
NOTICE OF INSURANCE INFORMATION PRACTICES
COLLECTION OF INFORMATION
This NOTICE is provided in compliance with your state's Insurance Information and Privacy Protection Act.
In order to provide insurance coverage on a fair and equitable basis, we must collect information about you and others for whom
coverage may be provided. This information may include age, occupation, physical condition, health history, prescription drug
records, general reputation, mode of living and other personal characteristics.
You will provide much of the information. We may collect or verify information by personal interviews and by otherwise contacting
Medical professionals and institutions, pharmacy benefit managers, employers, business associates, friends, neighbors and other
insurance companies. We may ask insurance support organizations to collect information and submit an investigative consumer report.
That organization may disclose the contents of the report to others for which it performs such services. You may request a copy of the
report or a personal interview in connection with it.
DISCLOSURE OF INFORMATION
The law allows disclosure of certain information without your authorization in response to a valid administration or judicial order, as
permitted or required by law, or to:
1. Persons or organizations performing professional, business or insurance functions for us;
2. Our agents, insurance support organizations or consumer reporting agencies;
3. Medical professionals and medical-care institutions;
4. Persons or organizations conducting bonafide actuarial or scientific research studies, audits or evaluations;
5. Insurance regulatory, law enforcement or other governmental authorities;
6. Persons or organizations involved in any sale, transfer, merger or consolidation of our business; and
7. Group Policyholders, certificate holders, professional peer review organizations, or persons having legal or beneficial interest in a
policy of insurance.
We do NOT disclose to our affiliates any information we receive about you from a consumer reporting agency. We do NOT disclose
your nonpublic personal information to third parties except as necessary to provide you our products and services.
We, or our reinsurers, may also release information in our file to other insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted.
MIB, Inc.
Information regarding your insurability will be treated as confidential. The Lincoln National Life Insurance Company or its reinsurers
may, however, make a brief report thereon to the MIB, Inc. formerly known as Medical Information Bureau, a not-for-profit
membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to
another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB,
upon request, will supply such company with the information about you in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866 692-6901.
If you question the accuracy of the information in the MIB's file, you may contact the MIB and seek a correction in accordance with
the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB's information office is 50 Braintree Hill Park,
Suite 400, Braintree, Massachusetts 02184-8734.
Information for consumers about MIB may be obtained on its website at www.mib.com.
PERSONAL DISCLOSURE
Also, you have a right to access personal information about you in our files. You may request that we correct, amend or delete
information you believe is inaccurate or irrelevant. A description of the appropriate procedures will be sent to you upon written
request.
TELEPHONE PERSONAL HISTORY REVIEW
After your application has been received in the Group Insurance Service Office, you may receive a telephone call from a specially
trained Group Insurance Service Office Interviewer who will ask you some questions to obtain verification or additional information.
If you have questions about the terms discussed in the NOTICE, please write to:
The Lincoln National Life Insurance Company
Group Insurance Service Office
P. O. Box 2616
Omaha, Nebraska 68103-2616
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Evidence of Insurability Cover Sheet (Samford University)

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Completed 26 August 2020

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