Fillable Medical History Statement MEMBER/EMPLOYEE INFORMATION Standard Insurance Company (Pensacola State College)

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Medical History Statement MEMBER/EMPLOYEE INFORMATION Standard Insurance Company (Pensacola State College)

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FL
SI 12985 1 of 3 (6/17)
Standard Insurance Company
Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204
Medical History Statement
For Residents of: Florida
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 Identication No.
MEMBER/EMPLOYEE INFORMATION
APPLICATION INFORMATION
Type of Application (check one) w Initial w Increase in Coverage w Late Application
Check the type and provide details on the amount of coverage you are requesting.
w Short Term Disability
w Long Term Disability + =
w Life + =
w Dependents Life + =
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
Check yes or no for each of these questions, and give details for any “yes” answers. Attach a separate sheet if necessary.
NOTE: Medical questions do not relate to Disability products for amounts over the Guaranteed Issue.
1. Are you now unable to maintain full time employment as dened by a licensed medical professional because of any
physical or mental condition, or injury? ..................................................................
Yes
No
2. Has a licensed member of the medical profession ever treated you for, diagnosed you as having, or prescribed medication for you for any of the following:
A. Disease of the liver, pancreas, kidney, ulcers, stomach, intestinal ailment, or any disease of the digestive system?
......
Yes
No
B. Multiple sclerosis, epilepsy, stroke, paralysis, numbness, visual disturbance, blindness, deafness, or any other
neurological or muscle disorder? ....................................................................
Yes
No
C. Cancer, tumor, lesions, leukemia, lymphoma, blood clotting or other malignancy or growth? ......................
Yes
No
D. Cardiovascular disease, heart ailment, arteriosclerosis, abnormal pulse, high blood pressure, heart murmur, valve,
circulatory, or vascular disease?.....................................................................
Yes
No
E. Emphysema, asthma, bronchitis, sleep apnea, or other respiratory or lung disease? ............................
Yes
No
F. Lupus, scleroderma, vasculitis, connective tissue disease, or an immune system disorder not related to Human
Immunodeciency Virus (HIV)? .....................................................................
Yes
No
G. Osteoarthritis, rheumatoid arthritis, osteoporosis, pain in the joints, amputations, or other disease or disorder of the
bones, joints, back, or spine, arthritic or disc conditions?..................................................
Yes
No
H. Diabetes, thyroid, gland, spleen, or nephritis? ..........................................................
Yes
No
I. Drug or alcohol abuse, or have you used alcohol, drugs or nicotine in a manner that has resulted in medical treatment?
....
Yes
No
J. Psychiatric or mental condition, depression, Adjustment Disorder (AD), Generalized Anxiety Disorder (GAD), or
Obsessive Compulsive Disorder (OCD)? ..............................................................
Yes
No
3. In the past 7 years have you had any illness or injury not listed above which resulted in the use of prescribed medication
or visits to a licensed member of the medical profession? ...................................................
Yes
No
4. Have you tested positive for exposure to the HIV infection or been diagnosed as having AIDS Related Complex (ARC) or
AIDS caused by the HIV infection or other sickness or condition derived from such infection? .......................
Yes
No
5. Have you been advised by a licensed medical professional to have any operation or to schedule an appointment for an
existing physical or mental condition, or injury? ...........................................................
Yes
No
6. Have you been diagnosed by a licensed medical professional as currently being pregnant? ........................
Yes
No
MEDICAL HISTORY STATEMENT QUESTIONS
Height Weight
Physician Name or Medical Facility with Applicant’s Complete Medical Records (provide name and full mailing address)
Read the Information Practices Notice(s) on page 3. A separate form must be submitted for each applicant (Employee/Member, Spouse and/or
Child) when Evidence Of Insurability or Proof of Good Health is required to apply for coverage. Complete all items, date and sign in the space at
the bottom of page 2. Keep a copy for your records, and send the original to Standard Insurance Company at the address given above.
DIRECTIONS FOR APPLYING FOR COVERAGE
Applicant’s Name (Person to be insured) Email Address
Street Address City State Zip Residency
Sex Birthdate (Mo/Day/Year) Birthplace
Social Security Number
Work Phone ( )
Home Phone ( )
w M w F
APPLICANT INFORMATION
w
USA
w
Other
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
Current Amount In Force, if any Additional Amount Requested Total Amount Requested
w
Member/Employee
w
Spouse
w
Child
Reset
FL
SI 12985 2 of 3 (6/17)
Applicant Name Social Security Number
Describe any “yes” answers below. (Please provide the entire question number.)
Question Description of Injuries, Disorders Month/Year Duration Final Result Physicians Consulted,
Number and Operations City & State
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.
•
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, 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 (The Standard) of any change in my medical condition while
my enrollment application is pending. I agree that if my application is approved by The Standard, 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, The Standard’s liability is limited to the return of any premium which may have been paid.
• To any health plan, physician, health care provider, hospital, clinic, laboratory, pharmacy, medical facility, insurance or reinsurance company, and
the MIB, Inc. (MIB), I instruct you to disclose my entire medical record and any other protected health information concerning me to The Standard
or its reinsurers. This includes information on any disorder of the immune system, including Acquired Immune Deciency Syndrome (AIDS) or
other related syndromes or complexes, and any communicable or sexually transmitted disease or disorder. This also includes information on the
diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.
•
By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this
authorization and I instruct any of the above to release and disclose my entire medical records without restriction.
•
I understand that The Standard will use information to determine my eligibility for group insurance coverage. I understand The Standard may
release information it has about me to its reinsurers and to any person performing business or legal services for The Standard in connection with
my application. I understand The Standard may release information it has about me to MIB for the purpose of reporting to the MIB information
exchange and for MIB to audit The Standard’s reporting. I understand The Standard may release information it has about me to other insurance
companies to which I have applied for insurance coverage or benets.
• I understand that information disclosed to The Standard pursuant to authorization may be subject to redisclosure with my authorization or as
otherwise permitted by law. Life and disability insurance coverages are not subject to the Privacy Rule under the Health Insurance Portability and
Accountability Act (HIPAA), and therefore release of information to The Standard is not protected under the Act.
• I understand that I am entitled to receive a copy of this authorization. This authorization will remain valid six months from the date of the signature
below. A photocopy or facsimile of this authorization shall be as valid as the original.
• I understand that I have the right to refuse to sign this authorization. I further understand that I have a right to revoke this authorization at any time
by sending a written statement to The Standard, except to the extent it has been relied upon to disclose requested records. I understand that the
revocation of the authorization, or the failure to sign the authorization, may impair The Standard’s ability to evaluate or process my application and
may be a basis for denying my application for insurance coverage.
•
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 beneciary designation on le with my plan administrator, I understand the
designation(s) on le will also apply to any approved amounts. If I have no beneciary designation(s) on le or I wish to change the name of
the current beneciary(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.
ACKNOWLEDGMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION (Please read carefully.)
FRAUD NOTICE
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, les a statement of claim or an application containing any
false, incomplete, or misleading information is guilty of a felony of the third degree.
Signature of Applicant (or Member/Employee for Dependent Child) Date
FL
SI 12985 3 of 3 (6/17)
•
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. (MIB), formerly known as Medical Information
Bureau. We will use the authorization you signed on this form when we seek this information.
•
MIB – Information regarding your insurability will be treated as condential. Standard Insurance Company or its reinsurers may, however, make a
brief report thereon to MIB, a not-for-prot 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 (including short and long term disability) insurance coverage, or a
claim for benets is submitted to such a company, MIB, upon request, will supply such company with the information in its le.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your le. Please contact MIB at 866-
692-6901. If you question the accuracy of information in MIB’s le, 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.
Standard Insurance Company may release information in its le to its reinsurers, and Standard Insurance Company, or its reinsurers, may
release information in its le to other insurance companies to whom you may apply for life or health (including short and long term disability)
insurance, or to whom a claim for benets may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.
•
DISCLOSURE TO OTHERS – The information collected about you is condential. 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 le. 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 justied. 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 or call 1-800-843-7979.
INFORMATION PRACTICES NOTICE
Applicant Name Social Security Number
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Medical History Statement MEMBEREMPLOYEE INFORMATION Standard Insurance Company (Pensacola State College)

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Completed 25 August 2020

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