Fillable Evidence-of-insurability-form - 67829

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Evidence-of-insurability-form - 67829

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Evidence of Insurability Statement
Life and Disability Coverage
Aetna Life Insurance Company
Read This Instruction Page Carefully.
Aetna may contact you directly to request additional information upon receipt of this completed Statement.
Instructions
Plan Sponso
r
Please Print
Complete Section A in its entirety. Be sure that:
• All items are completed.
• The Control Number, Suffix and Account numbers are provided (A1).
• The Employee/Member’s Social Security Number is provided (A2).
• Both the Employee/Member’s and your name and address are shown in the spaces provided (A3 and A4).
• The telephone number of your authorized representative (A5), Employee/Member’s date of hire (A6) and
Employee/Member’s home and work telephone numbers (A7) are provided.
• Your Employee/Member’s and your E-mail addresses are provided (A8 and A9).
• Employee/Member’s Annual Earnings is completed (A10).
• You check the appropriate box(es) for individual(s) requesting Life coverage. Provide the current amount of coverage,
requested additional amount of coverage, resulting total amount of coverage and Guarantee Issue amount for each
individual for whom coverage is being requested (A11).
• You check the reason for requested life coverage (A11).
• You check the appropriate Disability box(es) and provide current and requested amounts of coverage
(A11).
• Section A is signed by your Authorized Representative (A12).
Give the form to your Employee/Member for his/her confidential submission to Aetna.
Aetna will advise you of its coverage decision. Employee/Member will be notified directly if coverage is denied.
Employee/Member
Read the Privacy
Notice and
Misrepresentation
section on
“Page 2 of 4” of
the Insurability
Statement before
completing.
Please Print
Verify that your name, address and Social Security Number as shown in Section A are complete and accurate. We may need
to direct additional inquiries to your attention.
Complete Section B. Be sure that:
• All items are completed.
• Only the names of individuals requesting coverage at this time are listed (B1).
• Height and Weight must be provided or this form will be returned unprocessed for your completion (B1).
• The appropriate boxes regarding dependent child coverage are checked, if applicable (B2a, B2b, and B2c).
• Complete dates and details are given for all conditions checked in B3g, (B4).
• The form is signed by you. If you are requesting spouse coverage, the spouse’s signature is also required. Read the
Certification, Acknowledgment and Authorization prior to signing the form (bottom of Section B).
Make a copy for your records. Mail the original to:
Aetna Life Insurance Company
Medical Underwriting Department
PO Box 83641
Lincoln, NE 68501-3641
OR
Fax to (Applications within the US) : 1-800-792-9710
Fax to (International Applications Only): 1-402-474-8426
If you have any questions, call us toll-free at: 1-800-660-9913
If a final underwriting decision cannot be made within six months, Aetna reserves the right to request a new Evidence of
Insurability Statement.
Please Note: If this form is not completed in its entirety and signed, it will be returned unprocessed for your completion.
EOI PH Sign Req’d
GR-67853 (4-10) A-POD Make a copy for your records. Page 1 of 4
Privacy Notice
In evaluating your insurability, we (Aetna) will rely primarily on the health information you furnish to us in this Evidence of Insurability Statement. In addition, however, we may
ask you to take a physical examination, or request additional medical information about you from any of the sources specified in the authorization on Page 4 of 4 of this form.
Disclosure of Information to Others
All of this information will be treated as confidential and will not be disclosed to others without your authorization, except to the extent necessary for the conduct of our business
and not contrary to any law. For example, Aetna Life Insurance Company may also release information in its file to its reinsurer(s) and to other life insurance companies to
whom you may apply for coverage, or to whom a claim for benefits may be submitted. In addition, information may be furnished to regulators of our business and to others as
may be required by law, and to law enforcement authorities when necessary to prevent or prosecute fraud or other illegal activities.
Your Right of Access & Correction
In general, you have a right to learn the nature and substance of any information in our files about you. You also have a right of access to such files (except information which
relates to a claim or a civil or criminal proceeding), and to request correction, amendment or deletion of recorded personal information in states which provide such rights and
grant immunity to insurers providing such access. We may elect, however, to disclose details of any medical information you request to your (attending) physician. If you wish
to exercise this right, or if you wish to have a more detailed explanation of our information practices, please contact:
Aetna Life Insurance Company, Medical Underwriting Department, 151 Farmington Avenue, Hartford, CT 06156-2975
Under New Mexico law, a resident of New Mexico has the right to register as a "protected person" in connection with disclosure of confidential domestic abuse information. If
you wish to exercise this right, write to the address shown above.
Misrepresentation
Any person who knowingly and with intent to injure, defraud or deceive 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.
Attention Arkansas, Louisiana, Rhode Island and West Virginia Residents: 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. Attention California
Residents: For your protection, California law requires notice of the following to appear on this form: 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. Attention Colorado Residents: 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. Attention Florida Residents:
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. Attention Kansas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance
company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: 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 may subject such person to criminal and civil penalties.
Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly and willfully
presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for
an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York
Residents, the following statement applies only to your AD&D and Disability coverage: 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 shall be subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive 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 may be a crime and subjects such person to criminal and civil penalties. Attention
Ohio and Pennsylvania Residents: 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. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony. Attention Oregon Residents: Any person who with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may
have violated state law. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for
insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits
a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or
imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating
circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Vermont Residents: Any person who knowingly and with intent to injure,
defraud or deceive 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 may be a crime and may subject such person to criminal
and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an
application for in
surance 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 act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: 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.
Submission and Approval
The requested coverage will not be in effect unless and until evidence of insurability is submitted as required and is approved by Aetna
GR-67853 (4-10) Page 2 of 4
Evidence of Insurability Statement
Life and Disability Coverage
Aetna Life Insurance Company
Make a copy for your records.
Mail the original to:
Aetna Life Insurance Company
Medical Underwriting Department
PO Box 83641
Lincoln, NE 68501-3641
Customer Service: 1-800-660-9913
Fax to (Applications within the US): 1-800-792-9710 Fax to (International Applications Only): 1-402-474-8426
A. Plan Sponsor: Complete this Section - Please print.
1. Control Number Suffix Account
2. Employee/Member Social Security Number
3. Plan Sponsor Name & Address
ATTN:
Name
Street
City State ZIP Code
4. Employee/Member Name & Address
Street
City State ZIP Code
5. Plan Sponsor - Authorized Rep. Telephone Number
6. Employee/Member Date of Hire
(MM/DD/YYYY)
7. Employee/Member Telephone Numbers (Including Area Code)
Work Home
8. Plan Sponsor E-mail address
9. Employee/Member E-mail Address
10. Employee/Member’s Annual Earnings $
11. Coverage(s) Applied for:
Life* Employee/Member Basic Life Employee/Member Supplemental, Optional or Voluntary Life
Spouse Child(ren)
Employee/Member
Supplemental,
Employee/Member Optional or Spouse Child(ren)
Basic Life Voluntary Life Life Life
a. Current Amount of Life Insurance Coverage? $ $ $ $
b. Additional Amount of Life Insurance Coverage requested? $
$ $ $
c. Resulting Total Life Insurance Amount if Approved (a + b)? $
$ $ $
d. Guarantee Issue Amount of Life Insurance? $
$ $ $
*Reason for Requested Coverage (indicate all that apply).
Salary Increase Change in Multiple Late Applicant Change in Increments Life Event/Status Change
Requesting an Amount in Excess of Plan’s Guaranteed Issue Limit Other (Please explain)
Disability Coverages (Employee/Member Only):
Short Term Disability: Current Amount $ or % Requested Amount $ or %
Long Term Disability: Current Amount $ or % Requested Amount $ or %
12. I certify the above information is correct.
Plan Sponsor - Authorized Representative Signature Plan Sponsor - Authorized Representative Name (Please print) Date Signed (MM/DD/YYYY)
B. Employee/Member: Complete this Section - Please print. All questions must be answered. Incomplete forms cannot be processed.
1. Only the Names of Individual(s) Requesting Coverage at this Time Should be Listed
Name Relationship
Birthdate (MM/DD/YYYY)
Birthplace (City/State) Gender Height (ft., in.) Weight (lbs.)
Employee: Self
Spouse:
Child(ren):
2. Complete these questions if dependent children are listed above. Use Number 4 if additional space is needed.
Yes No
a. Do all dependent children live in your household? If No, please explain:
b. Do all dependent children depend solely on you for support? If No, please explain:
c. If any dependent child is age 19 or older, is/are they regularly attending school? If No, please explain:
EOI continued
GR-67853 (4-10) Page 3 of 4
#473398
Eastern Michigan University
140 McKenny Hall
Ypsilanti
MI
48197
B. Employee/Member: Complete this Section - Please print. (Continued)
3. Statement of Health for Individual(s) Listed Above. Please answer the following questions to the best of your knowledge and belief.
If any of the following questions are checked “Yes”, you must
provide details in Number 4 below.
Yes No
a. Is any individual pregnant? If Yes, Who: Date Due:
Any complications or problems:
b. Has any individual used tobacco products in the last 12 months (cigarettes, cigar, pipe, chewing tobacco)?
If Yes, Who:
c. Are any inpatient or outpatient medical, surgical or diagnostic procedures recommended or contemplated: If Yes, When:
Individual:
Name of procedure:
Reason for procedure:
d. In the past 7 years, has any individual been confined to a hospital, clinic, sanatorium, rehabilitation or other treatment facility?
If Yes, Who:
Why:
When:
e. In the past 7 years, has any individual been examined, monitored or received medical treatment from any doctor, practitioner or counselor
for any condition other than minor illnesses (cold, flu, etc.)?
If Yes, Who:
Why:
When:
f.
Is any individual(s) currently taking medication(s)? If Yes, complete the following information:
Name of Individual Medication Dosage/Frequency Diagnosis
g. Within the past 10 years have you, your spouse or child(ren) had any disease, impairment of or treatment (other than minor illnesses) for any of the
following? If Yes, check the appropriate box(es) and describe in Number 4.
AIDS* Cancer Immune System Disorder Nervous System
Arthritis Carpal Tunnel Syndrome Intestine/Stomach/Ulcer Paralysis/Paresis
Asthma/Emphysema/COPD Chest Pain Kidney/Bladder Reproductive System
Back/Spine/Neck Chronic Fatigue/Fibromyalgia Liver/Spleen/Pancreas Skin Disorder
Blood Disorder/Bleeding/Blood Clot Diabetes/Metabolic Lungs/Breathing Stroke
Blood Pressure/Hypertension Ears/Eyes Lupus Substance Abuse (Alcohol/Drug)
Blood Vessels/Circulation Epilepsy/Seizure Mental/Emotional Condition Throat/Tonsils/Swallowing
Bones/Joints Esophagus/Digestion/GERD Multiple Sclerosis Thyroid/Pituitary/Adrenal
Brain Heart Muscular Condition Tumor/Growth
Other
*AIDS (Acquired Immune Deficiency Syndrome) is a serious disease. It is caused by a virus called HIV (Human Immunodeficiency Virus). The virus
is found in some human body fluids of infected people, most notably in semen and blood. If the AIDS virus finds its way into the bloodstream, it can
damage the body’s defenses against disease, resulting in life-threatening diseases. There is no known cure.
4.
In the space below, describe all conditions checked in 3g above and provide additional information for questions 2a-c and 3a-f, if needed.
Ques. Name of Date of Details/ Treatments Full Recovery
No. Individual Diagnosis Onset Symptoms Received Date
Check here if you are providing additional information on a separate attachment.
Certification: I certify these answers and statements are complete and true to the best of my knowledge and belief. I will inform Aetna of any material changes to the information provided which take place
between the time the form is completed and the time coverage becomes effective. I agree that this document shall become a part of my request for group coverage and I acknowledge that I have retained a
copy of this document as completed by me.
Acknowledgment: I understand that, to the extent permitted by state law, false statements may result in the denial of claims or in my insurance coverage being void as of its effective date with no benefits
payable. I understand that conditions which are disclosed on this form may be subject to all conditions of my Plan Sponsor’s Plan including any preexisting condition limitations, fraud provisions and employee
actively at work and dependent health condition requirements. My signature indicates that I have reviewed all information and statements on this form for completeness and accuracy.
Authorization: To all physicians and other health professionals, hospitals and other health care institutions, insurers, medical or hospital service and prepaid health plans, employers and the Medical
Information Bureau: You are authorized to provide Aetna Life Insurance Company (Aetna) information concerning healthcare, advice, treatment or supplies (including those related to mental illness and/or
AIDS/ARC/HIV) provided me or any members of my family for whom coverage has been requested. (Minnesota residents are not required to provide information concerning results of AIDS/ARC/HIV tests
performed on a criminal offender or a crime victim.) I acknowledge that information obtained from any or all of the above may result in further underwriting investigation. This information will be used for the
purpose of determining eligibility for coverage. This authorization will be valid for twelve (12) months from the date signed. I acknowledge that I have read the Privacy Notice and Misrepresentation
section shown on “Page 2 of 4” of this form and know that I have a right to receive a copy of this authorization upon request. I agree that a photographic copy of this authorization is as valid as the
original.
Employee/Member’s or Authorized Person’s Signature (Required at
all times)
Date
Spouse’s or Authorized Person’s Signature (Required if spouse coverage is
requested)
Date
GR-67853 (4-10) Page 4 of 4
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Evidence-of-insurability-form - 67829

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Completed 19 February 2020

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