Fillable Georgia Insurability Information Request (City of Warner Robins)

Fill Online, Printable, Fillable, Blank Georgia Insurability Information Request (City of Warner Robins) Form

Use Fill to complete blank online CITY OF WARNER ROBINS (GA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Georgia Insurability Information Request (City of Warner Robins)

On average this form takes 29 minutes to complete

The Georgia Insurability Information Request (City of Warner Robins) form is 2 pages long and contains:

0 signatures
7 check-boxes
112 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Warner Robins

BROWSE CITY OF WARNER ROBINS (GA) FORMS

Related forms

Fill has a huge library of thousands of forms all set up to be filled in easily and signed.

Fill in your chosen form

Sign the form using our drawing tool

Send to someone else to fill in and sign.

find another form

Si usted necesita ayuda en Español para entender este documento, puede solicitarlo sin ningun costo adicional llamando al número de servicio al cliente que se encuentra en este documento.

Life and Disability products underwritten by Greater Georgia Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association.

The Blue Cross and Blue Shield names and symbols are registered m arks of the Blue Cross and Blue Shield Association.

1 of 2

Georgia Insurability Information Request

Please keep a copy of this form/notice for your records

G-0711-EOI

Greater Georgia Insurance Company

PO Box 182361

Columbus, OH 43218-2361

Phone 800-551-7265

Fax 614-433-8880

32641GAMENGGL 12/12

Greater Georgia Insurance Company

Life Underwriting Unit

PO Box 4510

Woodland Hills, CA 91365

Evidence required because of: This evidence is provided for:

Over guaranteed issue amount Late entrant Change of beneﬁts An effective date under a new group A post group effective date addition

SECTION 1:

GENERAL INFORMATION

Last name First name M.I. Date of birth (MM/DD/YYYY)

Social Security no. Work phone no. Home phone no. Email address

Employee address City State ZIP code State of birth Height Weight

Name of employer Employer address

SECTION 2:

DEPENDENT INFORMATION – Complete for all dependents (if any) to be covered under this program.

Last name, ﬁrst name, M.I. Sex

Date of birth

(MM/DD/YYYY)

State of

birth

Social Security no. Relationship Height Weight

Spouse

SECTION 3:

MEDICAL AND ACTIVITIES QUESTIONNAIRE

COMPLETE THE FOLLOWING MEDICAL QUESTIONS FOR ALL PERSONS TO BE COVERED: For the purpose of the following questions, the term “medical or social practitioner”

includes but is not limited to: a doctor, nurse, psychologist, psychiatrist, social worker, chiropractor, podiatrist, therapist, pathologist, dentist, optometrist, osteopath,

Christian Science practitioner, or any person afﬁliated with a self-help program such as Alcoholics Anonymous, a substance abuse program, or a weight loss program.

1. Are you or any of your dependents currently pregnant?

If yes, who?___________________________

Expected due date___________________(MM/DD/YYYY)

Yes No

4. Have you or any of your dependents ever been diagnosed by,

or received treatment from, a member of the medical profession

for Acquired Immune Deﬁciency Syndrome (AIDS) or AIDS-Related

Complex (ARC) or tested positive for antibodies to the Human

Immune Deﬁciency virus?

Yes No

2. Have you or any of your dependents smoked or used tobacco in

the last ﬁve years?

If yes, who _________________________

Type _____________________________

Quit date (if applicable) ________________(MM/DD/YYYY)

Yes No

5. In the past three years have you or any of your dependents been

prescribed medication?

Yes No

6. In the past 10 years have you or any of your dependents had an

inpatient admission and/or outpatient surgery?

Yes No

3. In the past 10 years, have you or any of your dependents ever

been diagnosed by or received treatment from a member of the

medical profession?

a. for high blood pressure or high cholesterol?

If yes, who_______________________________

Last three readings__________________________

b. for heart disease, cancer, diabetes, arthritis, or asthma?

c. Had counseling by a medical or social practitioner for an

emotional, mental or nervous condition?

d. Been treated for alcohol or chemical dependency, or been

convicted for driving while intoxicated?

Yes No

7. During the past 3 years, have you or any of your dependents

sought medical treatment, or been advised by a medical or social

practitioner to seek treatment for any condition not indicated by

the answers to the preceding six questions?

Yes No

8. Have you or any of your dependents ever been rated or declined

for, or refused reinstatement or renewal of, life or health

insurance? If yes, name of person, date and reason:_________

_________________________________________

Yes No

9. In the past 3 years, have you or any of your dependents been

engaged in or contemplate during the next 12 months being

engaged in sports or hobbies such as aviation, scuba diving, sky

diving, or racing?

Please list: __________________________________

Yes No

IMPORTANT NOTICE: No person, including an employee or agent of Greater Georgia Life has the authority to change or omit any of these medical questions.

645133 32641COEENLIC Disability and Life Employer EOI FR 10 12

Group no.

2 of 2

SECTION 3: MEDICAL AND ACTIVITIES QUESTIONNAIRE (continued)

Explain any “Yes” answers below. If additional space is necessary, attach a separate page including your signature and date.

Question

no.

Name of individual

Name of illness or

injury

Dates of

treatment

Any remaining

effects

Name of medication

and dosage

Name and address of

physician/hospital

SECTION 4:

NOTICE OF EXCHANGE OF INFORMATION

To proposed Insured and other persons proposed to be Insured, if any — information regarding your insurability will be treated as conﬁdential. We or our reinsurer(s) may,

however, make a brief report on this information to MIB, Inc., a non-proﬁt membership organization of insurance companies that 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 may, upon request,

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. If you question the

accuracy of this 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: 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734; and telephone number is 866-692-6901.

SECTION 5:

AGREEMENT AND AUTHORIZATION

1. I authorize the release of any medical records or information concerning claims, conditions or treatment of myself and for any dependents listed herein,

by any provider of health services, pharmacy related service organization, medical or medically-related facility, or the MIB, Inc., to Greater Georgia

Life Insurance Company (Greater Georgia Life), its afﬁliates, and any administrators, reinsurers, agents, or other entity providing services on behalf of

Greater Georgia Life. This information will be used for purposes which include but are not limited to: processing this application for enrollment; group risk

classiﬁcation; detecting or preventing fraud or misrepresentation; internal and external audits; administration of claims; and quality improvement programs.

Greater Georgia Life will advise such entities that such information must be kept conﬁdential to the extent necessary or as otherwise provided by law, and

should not be used for any unlawful purpose. This information includes any records or knowledge about medical history, including sensitive services such

as mental health, psychiatric, substance abuse, reproductive health, information relating to HIV virus or AIDS, sexually transmitted or other communicable

diseases contained in such records, including but not limited to, all records of ofﬁce visits, examinations, treatment, evaluation, diagnostic

and laboratory testing, reports, consultations, hospital records, prescription history, records for treatment of substance abuse, psychiatric counseling,

notes, correspondence, insurance and billing information for treatment or services rendered by any provider. I understand that Greater Georgia Life may

collect personal information about me from outside sources, and that both personal and privileged information may be collected and disclosed to third

parties without my further authorization, and may no longer be protected by Federal privacy laws. I also understand that I have a right to see and correct

personal information that Greater Georgia Life collects about me, and that I may receive a more detailed description of my rights under this law by writing

to Greater Georgia Life.

2. These coverages will become effective on the date established by the provisions of the group contract and certiﬁcates issued thereunder.

3. I am responsible for the timely notiﬁcation to my employer of any changes that would make me or a dependent ineligible for coverage.

4. I understand that Greater Georgia Life Insurance Company reserves the right to accept or decline the application and that no right whatsoever is created

by this information request. I acknowledge that I have read the foregoing provisions and I expressly accept such provisions as a condition of coverage. I

also acknowledge receipt and understanding of the Notice of Exchange of Information explained above. I represent that the answers given to all questions

on this information request are true and accurate to the best of my knowledge and I understand they are being relied on by the insurer in reviewing the

application for insurance. I understand that any misstatements or failure to report new medical information prior to my effective date may result in a

material change to coverage or premium rates. Any material misrepresentation or signiﬁcant omission found in this information request may result in denial

of beneﬁts or rescission or cancellation of my coverage(s). This authorization, for purposes of processing this information request form, is valid from the

date signed for a period of thirty months unless revoked by me in writing, which I may do at any time by contacting Greater Georgia Life. A photocopy is as

valid as the original.

Applicant signature Date (MM/DD/YYYY)

Spouse signature (If to be covered) Date (MM/DD/YYYY)

This Authorization may be revoked at any time by the Applicant by sending a written revocation to us at: Greater Georgia, PO Box 182361, Columbus, OH, 43218-2361. Such

revocation must be signed and dated by the Applicant and spouse, if the spouse is to be covered. Revocation of this Authorization may result in denial of coverage or denial

of a claim.

REFUSAL OF AUTHORIZATION – I refuse authorization to disclose health care information. I understand that such refusal may result in denial of coverage or denial of a claim.

Applicant signature Date (MM/DD/YYYY)

Spouse signature (If to be covered) Date (MM/DD/YYYY)

Fraud Warning for Georgia: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, ﬁles a statement of claim or an application containing any false, incomplete,

or misleading information is guilty of a crime and may be subject to criminal and civil penalties.

Fillable Georgia Insurability Information Request (City of Warner Robins)

Fill Online, Printable, Fillable, Blank Georgia Insurability Information Request (City of Warner Robins) Form

Related forms

First 20 documents completely FREE!