Fillable Evidence of Insurability (EOI) (City of Houston)

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Evidence of Insurability (EOI) (City of Houston)

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PART 2: TO BE COMPLETED BY EMPLOYEE - This section contains essential information and leaving any item blank will
cause a delay in processing your insurance request.
YOU MUST COMPLETE ALL PAGES OF THIS APPLICATION IN ORDER TO BE CONSIDERED FOR COVERAGE.
Retain a copy of this application for your records.
EMPLOYEE
Name Last First M.I. Date of Birth Age Sex State of Birth
/ /
q
M q
F
Home Mailing Address - Street City State Zip Work Telephone Home Telephone
( ) ( )
Social Security # Height ft. in. Weight lbs.
Evidence of Insurability (EOI)
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
SPOUSE-DO NOT complete spouse information unless you are applying for dependent spouse coverage.
Name Last First M.I. Date of Birth Age Sex State of Birth
/ / q
M q
F
Social Security # Height ft. in. Weight lbs.
CHILD(REN) - DO NOT complete this section unless you are applying for dependent child(ren) life insurance which is
subject to satisfactory evidence of insurability (for example, a late enrollment.) Evidence of insurability
is not required for voluntary dependent child term life coverage.
FOR DEARBORN NATIONAL USE ONLY
Group Number ___________________________
Group Name and Address
Group Contact ____________________________
(Print Name)
Group Contact ____________________________
(Print Title)
Telephone (______) ________________________
Fax (______) _____________________________
PART 1: TO BE COMPLETED BY GROUP ADMINISTRATOR/
EMPLOYER
(Please Print and submit with copy of employee
enrollment form)
EMPLOYEE
q Approved
q Declined
q Closed
q Smoker
q Nonsmoker
GI qYes qNo
$___________
Amount Approved
$________________
Effective Date*
Reviewed by & date
_________________
SPOUSE
q Approved
q Declined
q Closed
q Smoker
q Nonsmoker
GI qYes qNo
$___________
Amount Approved
$________________
Effective Date*
Reviewed by & date
_________________
CHILD(REN)
q Approved
q Declined
q Closed
Amount Approved
$________________
Effective Date*
Reviewed by & date
_________________
State Code ________
Agency (CB)(TPA)
__________________
q
SAWEB
q
Self-Admin
q
Direct Bill _______
Reason for EOI:
q Amount over
Guarantee Issue
q Late Enrollment
q Other
____________
If New Hire, Indicate
Eligibility Waiting Period
____________________
Policy Anniversary Date
____________________
*The effective date of coverage is the date the application is approved.
Premium is due the first of the month following the approval date.
Do not deduct premiums for any coverage subject to evidence of
insurability until you receive Dearborn National’s final confirmation
of approval.
Dependent Child Full Name SS# Date of Birth Age Sex Ht & Wt
q M q F
q M q F
q M q F
R0712_12 I Z4306Page 1 of 4
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
9-551-412
F019122
City of Houston
611 Walker Street, 4th floor
Houston, TX 77002
EMPLOYEE Supp Amount Elected _____________ Dependent Supp Elected?
Spouse ______ Child(ren) ______
Check either “Yes” or “No” to each question and circle the specic
condition(s). Details to all “yes” answers must be provided below.
Failure to provide full information or providing false information may
result in denial of benets and/or possible investigation for fraud.
Employee
Yes No
Spouse
Yes No
Child(ren)
Yes No
1. Has any person applying for coverage been seen, treated, advised or received
services from any health provider in the last 12 months, including routine
physicals? qYes qNo
qYes qNo qYes qNo
2. Within the last 7 years, has any person applying for coverage had
symptoms, been diagnosed with and/or received treatment by/from
a member of the health profession for any of the conditions listed in the
questions below?
a. High blood pressure, heart attack, chest pain, shortness of breath, irregular
heartbeat, murmur, coronary artery disease, heart surgery (catheterization/
angioplasty/bypass, etc.), or any other disease or disorder of the heart or
circulatory system?
qYes qNo qYes qNo qYes qNo
b. Enlarged glands, thyroid disorder, diabetes, abnormal glucose level, hepatitis,
cirrhosis, abnormal liver studies, hernia, ulcer, colitis or any other disease or
disorder of the liver, endocrine, or digestive system?
qYes qNo qYes qNo qYes qNo
c. Alcohol and/or drug abuse/addiction/treatment, depression, anxiety, bipolar,
ADD/ADHD, anorexia, bulimia or any other mental/nervous/behavioral disorder?
qYes qNo qYes qNo qYes qNo
d. Asthma, emphysema, tuberculosis, pneumonia, COPD, sleep apnea, or any
other disease or disorder of the throat, lungs, or respiratory tract?
qYes qNo qYes qNo qYes qNo
e. Prostate, uterus/tubes/ovaries, endometriosis, cystitis, kidney stone, renal
failure, sexually transmitted diseases, any disorder of the kidneys/bladder/
urinary tract, breast lumps/changes/biopsies, abnormal test results or any
other male/female disorder?
qYes qNo qYes qNo qYes qNo
f. Cancer, tumor, cyst, moles, polyps, growth or any skin disorder (indicate
location and if benign/malignant)?
qYes qNo qYes qNo qYes qNo
g.
Stroke, paralysis, convulsions, seizures, epilepsy, fainting, headaches,
dizziness, or any other disease or disorder of the nervous system?
qYes qNo qYes qNo qYes qNo
h.
Arthritis, gout, rheumatism, neck or back strain/sprain/injury, deformity, loss of
limb, or any other disease or disorder of the back, spine, muscles, bones or joints?
qYes qNo qYes qNo qYes qNo
3. Has any person applying for coverage been diagnosed with or received
treatment for an immune system disorder, including AIDS-Related Complex
(ARC), Acquired Immune Deciency Syndrome (AIDS), or tested positive for
antibodies to the AIDS (Human Immunodeciency) Virus?
qYes qNo qYes qNo qYes qNo
4. Does any person applying for coverage currently take medication (prescription
or otherwise), been prescribed medication, or has any person done so in the
last 6 months?
qYes qNo qYes qNo qYes qNo
5. Within the last 2 years, has any person applying for coverage had a physical
disability, surgery, or been conned to a hospital, skilled nursing or rehabilitation
facility, undergone any special examinations or laboratory tests such as x-rays,
electrocardiograms, MRI, CAT Scans, PET or CT Scans, biopsies, blood or
urine tests; or had any medical advice, examination, consultation or treatment;
and/or been advised of future surgery, treatment, therapy, hospitalization, testing
or evaluation to be performed, not mentioned in questions 1 through 3?
qYes qNo qYes qNo qYes qNo
6. Is any person applying for coverage currently pregnant? If “Yes”, indicate
anticipated delivery date ______________. Provide details of any current/
prior complications on Page 3.
qYes qNo qYes qNo qYes qNo
7. Has any person applying for coverage EVER HAD symptoms, been diagnosed
with, and/or received treatment from a member of the health profession for ANY
HEALTH CONDITION other than those conditions listed above?
qYes qNo qYes qNo qYes qNo
Part 3: Health Information (Answer all questions fully, accurately, and truthfully for any person applying for coverage.)
Evidence of Insurability (EOI)
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
R0712_12 I Z4306Page 2 of 4
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
9-551-412
Employee Name ________________________________________ Social Security # ____________________________
# Person Type of
Condition
Dates Hospitalized
Yes No
Surgery
Yes No
Treatment/
Medication
Current
Meds/
Remaining
Problems
Physician’s Name,
Address & Phone#
Employee
Yes No
Spouse
Yes No
Child(ren)
Yes No
8. Has any person applying for coverage used cigarettes or other tobacco
products in the last 2 years?
qYes qNo qYes qNo qYes qNo
9. Has any person applying for coverage been rated, declined, postponed or
limited in any way for life, health, accident or disability insurance?
qYes qNo
qYes qNo qYes qNo
Part 3: (Continued): Health Information (Answer all questions fully, accurately, and truthfully for any person applying
for coverage.)
PART 4: Provide details of all 'YES' answers given to questions in PART 3. – If additional space is required, attach a
separate signed and dated sheet.
Evidence of Insurability (EOI)
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
R0712_12 I Z4306Page 3 of 4
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
9-551-412
Employee Name ________________________________________ Social Security # ____________________________
No premiums may be deducted on amounts subject to evidence of insurability until a final decision regarding approval of
coverage is received by your employer from Dearborn National
®
Life Insurance Company.
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose
of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and
subjects such person to criminal and civil penalties. (Not enforceable in Oregon or Virginia.)
AGREEMENTS AND AUTHORIZATION: I, the undersigned applicant(s), have read and agree that the above statements
are complete, true and correctly recorded to the best of my knowledge and belief. Further, I understand Dearborn National
Life Insurance Company (Dearborn National) shall not be liable for any claim arising prior to the date of approval of this
application at Dearborn National’s Home Office.
To determine my eligibility for the coverages applied for, I authorize any medical professional, hospital, clinic or other
medical or medically-related facility, medical provider, the MIB Group, Inc., or any Covered Entity or Health Plan as defined
by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to disclose to Dearborn National’s underwriting
department or its authorized representative(s) my medical records, or that of my children, including information concerning
advice, care or treatment for any condition, including but not limited to drug or alcohol use or abuse, mental illness, HIV
(AIDS Virus) or other sexually transmitted diseases.
I further authorize Dearborn National to disclose the information obtained in the consideration of my application for
insurance to its reinsurers and the MIB Group, Inc. a non-profit membership organization of life insurance companies
which operates an information exchange on behalf of its members.
This authorization shall expire 24 months from the date it is signed. I understand and agree that:
• I may revoke this authorization at any time, but that such a revocation will have no effect on any actions taken by
Dearborn National prior to receipt of the revocation;
• Information provided pursuant to this authorization may be redisclosed by the recipient and no longer subject to the
protections of the HIPAA Privacy Rule;
• I should retain a duplicate copy of this authorization for my own records;
• A photocopy of this authorization shall be as valid as the original;
• I have received a Disclosure Statement; and
• Coverage will not become effective until Dearborn National approves my application, provided that I am actively at
work on that day
I as well as any other person authorized to act on my behalf or my personal representative, acknowledge the right upon
request to obtain a true copy of this authorization from Dearborn National.
If my answers on this application are incorrect or untrue, or if I refuse to sign this authorization, Dearborn National has the
right to deny benefits or rescind my coverage or that of my dependents, if applicable.
Evidence of Insurability (EOI)
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
___________________________________________________________________ __________________________
Signature of Employee Date
___________________________________________________________________ __________________________
Signature of Spouse (if requesting insurance) Date
___________________________________________________________________ __________________________
Signature of Dependent Child (if to be insured and of age of majority) Date
R0712_12 I Z4306Page 4 of 4
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
9-551-412
Disclosure
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
(Please retain with your insurance records)
Thank you for enrolling for Group Insurance with Dearborn National
®
Life Insurance
Company. To assist us in processing the group policy, your signature on the Agreements and
Authorization section of the Evidence of Insurability form authorizes information concerning
proposed insureds to be released relative to each person’s insurability. You or your personal
representative are entitled to receive a copy of this authorization.
Information regarding your insurability will be treated as confidential. Dearborn National
®
Life Insurance Company or its designated representative(s) may, however, make a brief
report thereon to the Medical Information Bureau, a non-profit membership organization,
of life insurance companies which operates as an information exchange on behalf of its
members. If you apply 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 each 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. 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 MA 02112, telephone number 866-692-6901
(TTY 866-346-3642).
Dearborn National
®
Life Insurance Company, its reinsurers, or designated representative(s)
may also release information in its file 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.
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 1 of 1
R0711_12 I Z4567
R0516_12 | Z6291
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 1 of 2
The laws of some states require us to furnish you with the following notice:
FOR APPLICATIONS AND CLAIMS:
Colorado: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of
an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of
insurance within the department of regulatory agencies.
District of Columbia: WARNING: It is a crime to
provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by
the applicant.
Florida: 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.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment
of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or a statement of claim
containing any materially false information or conceals,
for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime.
Louisiana: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Maine & Washington: It is a crime to knowingly
provide false, incomplete, or misleading information to
an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and
denial of insurance benefits.
Maryland: Any person who knowingly or willingly
presents a false or fraudulent claim for payment of a loss
or benefit or who knowingly or willfully presents false
information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
New Mexico: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim
for the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with
intent to defraud any insurance company or other person
files an application for insurance or statement of claim
containing any materially false information or conceals for
the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal
and civil penalties.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of
a loss or any other benefit, or presents more than one
claim for the same damage or loss, shall incur a felony
and, upon conviction, shall be sanctioned for each
violation with the penalty of a fine of not less than five
thousand dollars($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years,
if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or benefit
or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Tennessee: It is a crime to knowingly provide false
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits
Virginia: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance
company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of
insurance benefits.
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
Fraud Notices
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Alaska: A person who knowingly and with
intent to injure, defraud, or deceive an
insurance company files a claim containing
false, incomplete, or misleading information
may be prosecuted under state law.
Arizona: For your protection, Arizona law
requires the following statement to appear on
this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss
is subject to criminal and civil penalties.
Arkansas: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
California: For your protection California law
requires the following to appear on this form.
Any person who knowingly presents false or
fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines
and confinement in state prison.
Delaware: Any person who knowingly, and
with intent to injure, defraud or deceive any
insurer, files a statement of claim containing
any false, incomplete or misleading information
is guilty of a felony.
Idaho: Any person who knowingly, and with
intent to defraud or deceive any insurance
company, files a statement or claim containing
false, incomplete, or misleading information is
guilty of a felony.
Indiana: A person who knowingly and with
intent to defraud an insurer files a statement
of claim containing any false, incomplete, or
misleading information commits a felony.
Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files
a statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Texas: Any person who knowingly presents a
false or fraudulent claim for the payment of a
loss is guilty of a crime and may be subject to
fines and confinement in state prison.
FOR APPLICATIONS ONLY:
Massachusetts: Any person who knowingly
presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false
information in an application for insurance is
guilty of a crime and may be subject to fines
and confinement in prison.
New Jersey: Any person who includes
any false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
R0516_12 | Z6291
Products and services marketed under the Dearborn National
®
brand and the star logo are underwritten and/or provided by Dearborn National
®
Life Insurance Company
(Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
Page 2 of 2
Administrative Ofces: Downers Grove, Illinois | Dallas, Texas
Fraud Notices
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Evidence of Insurability (EOI) (City of Houston)

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Completed 8 March 2022

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