Fillable Form SI 9340 Medical History Statement standard insurance

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Form SI 9340 Medical History Statement standard insurance

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SI 9340 1 of 3 (11/05)
Standard Insurance Company Medical History Statement
Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204-1282
This form must be completed when Evidence Of Insurability is required. To apply for coverage (as a Member/Employee, Spouse or
Child), read the Information Practices Notice(s). Then complete all items, date, and sign as instructed. Send the original to Standard
Insurance Company, at the address above. Please keep a copy for your records.
DIRECTIONS FOR APPLYING FOR COVERAGE
Check yes or no for each of these questions, and give details for any “yes” answers. Attach a separate sheet if necessary.
1. Have you had any physical, mental or emotional condition, injury, sickness, or surgery in the past 5 years? . . . . . . . . . . . . . Ye s No
2. Have you consulted or been attended by a physician or practitioner for any cause in the past 5 years? . . . . . . . . . . . . . . . . .
Ye s No
3. Are you now unable to work full-time because of any physical, mental or emotional condition, injury, or sickness? . . . . . . . .
Ye s No
4. Has a medical professional ever treated you for, diagnosed you as having, or prescribed medication for you for any
of the following:
A. High blood pressure, cardiovascular disease, heart ailment, arteriosclerosis, or stroke? . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
B. Mental condition, depression, epilepsy, or nervous system disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
C. Cancer, diabetes, or nephritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
D. Arthritis, strained or injured back, slipped disc, or any bone, joint, or muscle disorder? . . . . . . . . . . . . . . . . . . . . . . . . .
Ye s No
E. Lung, kidney, stomach, genital, urinary, liver, pancreas, or intestinal ailment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
F. Blindness or deafness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
G. An immune system disorder not related to Human Immunodeficiency Virus (HIV)? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ye s No
5. Has a medical professional ever diagnosed you as having or prescribed medication to you for Acquired Immune
Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or HIV infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ye s No
6. Have you sought or received advice or treatment for the use of alcohol or drugs in the past 10 years? . . . . . . . . . . . . . . . . .
Ye s No
7. In the past 10 years have you had a persistent cough, unintentional weight loss of 10 pounds or more, persistent
fatigue, persistent lymph node enlargement, prolonged night sweats, pneumonia, lesions, or growths? . . . . . . . . . . . . . . . . .
Ye s No
8. Do you take medication for any physical, mental or emotional condition, injury, or sickness? . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
9. Do you plan any operation or visit to a doctor or practitioner for an existing physical, mental or emotional condition,
injury, or sickness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
10. Have you ever been declined for insurance or offered a rated or restricted policy, either as a new policy or reinstatement? . . Ye s No
11. Are you now pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
Height Weight Physician or Medical Facility with Applicant’s Complete Medical Records
Name and Full Mailing Address
MEDICAL HISTORY STATEMENT QUESTIONS
APPLICATION INFORMATION
Type of Application
(check one)
Initial
Increase in coverage
Late Application
Check the insurance coverage you are requesting.
Short Term Disability
Long Term Disability + =
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
Life + =
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
Dependents Life + =
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
Applicant’s Name (Person to be insured) Street Address City State Zip
Sex Birthdate
(Mo/Day/Year) Birthplace Social Security Number Work Phone ( )
Home Phone ( )
M
F
APPLICANT INFORMATION
Name of Group Group Number Check who is Applying (One per form)
Member/Employee Name Birthdate (Mo/Day/Year) Date Hired (Mo/Day/Year)
Occupation Salary Social Security Number Member/Employee Identification No.
MEMBER/EMPLOYEE INFORMATION
Member/Employee
Spouse
Child
Reset
SI 9340 2 of 3 (11/05)
Applicant Name
(to be completed if applying online)
Social Security Number
Describe below any “yes” answers. (Please provide the entire question number.)
Question Description of Injuries, Disorders Month/Year Duration Final Result Physicians Consulted,
Number and Operations City & State
•
I represent that the statements contained herein, including those made in response to the Medical History Statement questions and any attachments,
are true and complete, to the best of my knowledge and belief, and I understand that they form the basis of any coverage under the Group
Policy(ies). I understand that any misstatements or failure to report information which is material to the issuance of coverage may be used as a
basis for rescission of my insurance and/or denial of payment of a claim. I agree to notify Standard Insurance Company of any change in my
medical condition while my enrollment application is pending. I agree that if my application is approved by Standard Insurance Company, the
effective date of any coverage will be determined in accordance with the terms of the Group Policy(ies), including any applicable Active Work
requirement. I agree that if my application is declined, Standard Insurance Company’s liability is limited to the return of any premium which may
have been paid.
•
To any physician, health care provider, hospital, insurance or reinsurance company, the Medical Information Bureau, Inc. (MIB), or any employer:
I authorize you to release to Standard Insurance Company or its reinsurers all medical information you have about me including medical history,
diagnosis, prognosis and treatment of any physical, mental or emotional condition. I understand that Standard Insurance Company will use the
information obtained by this authorization to determine my eligibility for group insurance coverage. I further authorize Standard Insurance Company to
release this information to its reinsurers, MIB, and to other insurance companies to which I have applied for insurance coverage or benefits.
•
I understand that if my application is approved, premiums shall be paid in accordance with the provisions of the Group Policy(ies), and my coverage
will be subject to all terms and conditions of the Group Policy(ies) and state limitations.
• For Member/Employee: If I currently have a Life and/or Trust Life beneficiary designation on file with my plan administrator, I understand the
designation(s) on file will also apply to any approved amounts. If I have no beneficiary designation(s) on file or I wish to change the name of
the current beneficiary(ies), I will contact my plan administrator.
• I understand that insurance on a Spouse or other Dependent, if any, is payable to the Member/Employee, if living, or as provided under the terms
of the Group Policy(ies).
•
I acknowledge that I have read and received the Information Practices Notice and I have kept a copy of this Medical History Statement.
•
I understand a copy of this authorization will be provided to me, or my authorized representative, upon request. This authorization will remain valid
one year from the date below. A photocopy of this authorization shall be as valid as the original.
• I understand that I have the right to revoke this authorization at any time by sending a written statement to Standard Insurance Company. I further
understand that the revocation of the authorization, or the failure to sign the authorization, may impair Standard Insurance Company’s ability to
evaluate or process my application and may be a basis for denying my application for insurance coverage.
Signature of Applicant (or Member/Employee for Dependent Child) Dated
ACKNOWLEDGMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION (Please read carefully)
Note: Declinations do not affect either Guarantee Issue Amounts not subject to Evidence Of Insurability or other coverages already in force
with Standard Insurance Company.
SI 9340 3 of 3 (11/05)
Applicant Name
(to be completed if applying online)
Social Security Number
• To help us determine your eligibility for group insurance we may request information about you from other persons and organizations.
For example, we may request information from your doctor or hospital, other insurance companies, or MIB, Inc. (Medical Information Bureau).
We will use the authorization you signed on this form when we seek this information.
• MIB (MEDICAL INFORMATION BUREAU) – Information regarding your insurability will be treated as confidential. Standard Insurance Company
or its reinsurers may, however, make a brief report thereon to MIB, 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 in its file.
Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901
(TTY 866-346-3642). If you question the accuracy of information in MIB’s file, you may contact 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: Post Office Box 105, Essex Station,
Boston, Massachusetts 02112.
Standard Insurance Company may release information in its file to its reinsurers, and Standard Insurance Company, or its reinsurers,
may release information in its 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.
• DISCLOSURE TO OTHERS – The information collected about you is confidential. We will not release any information about you without your
authorization, except to the extent necessary to conduct our business or as required or permitted by law.
• YOUR RIGHTS – You have a right to know what information we have about you in our underwriting file. You also have a right to ask us to correct
any information you think is incorrect. We will carefully review your request and make changes when justified. If you would like more information
about this right or our information practices please write to us, at Medical Underwriting, Standard Insurance Company, 900 SW Fifth Avenue,
Portland, Oregon 97204-1282 or call 1-800-843-7979.
INFORMATION PRACTICES NOTICE
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Completed 20 February 2020

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