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EVIDENCE OF INSURABILITY GL-152576
Reliance Standard Life Insurance Company Home Office—Chicago, Illinois
Administrative Office—Philadelphia, Pennsylvania
EMPLOYEE/MEMBER INSTRUCTIONS:
•
Enter information requested for yourself and/or each dependent to be insured.
•
Answer each health question “yes” or “no” or the form will be returned.
•
Name of Employee/Member:
Soc
ial Security No.:
Address:
Home Telephone
Number:
E-mail:
Policy No.
Reason for Evidence and Amount Applied For:
Hire Date Eligibility Date: If approved, coverage will become effective as of the date indicated below,
provided: (1) the employee was actively at work; and (2) dependents were not
hospital or home confined on that date.
FOR RELIANCE STANDARD LIFE USE ONLY:
NOTICE OF ACTION The following action has been taken with respect to the
evidence of insurability submitted by the:
Employee/Member: __Approved __ Declined __Incomplete
This Evidence For:
Employee/Member only
Dependents only
Employee/Member & Dependents
Spouse:
Child:
__Approved
__ Approved
__ Declined
__ Declined
__Incomplete
__Incomplete
Employer’s Name & Address
Effective Date if Approved:
Signed – Group Underwriter
Date
Names Of Proposed Insureds Occupation
Annual
Salary
Gender
Date Of
Birth
Place Of
Birth
Height Weight
Self:
Spouse:
Social Security No.:
Dependent Children:
(use separate sheet for a
dditional
dependents)
Page 1
LRS-9115-0102-FL
Nova Southeastern University
Office of Human Resources
3301 SW 9th Avenue
Fort Lauderdale, Florida 33315
954-262-4748 - HR4U@nova.edu
Completed by:
Joshua Appelt, Manager of Employee Benefits
Email form directly to EOIApplications@rsli.com
•
Upload a copy of the form directly to your Employee File in the ICUBA
Benefits Portal online at http://icubabenefits.org
04/01/2017
GL-152576
04/1/2019
Reset
Other
Spouse Coverage Amount Requested
Spouse Coverage Amount Requested
Ft.
In.
Ft.
In.
Ft.
In.
Ft.
In.
Ft.
In.
Ft.
Ft.
In.
In.
1. Have you or any Proposed Insured been diagnosed or treated by a licensed medical professional for any of the
following within the past 5 years: (Underline the condition and record details in space provided.)
Yes No
Yes No
a. Eye or ear: disease; disorder; or impairment?
b. Diabetes; goiter; tumor; cancer; or growth of any
kind?
c. Rheumatism; arthritis;
gout; spine; or back
trouble
?
d. Disease of the nervous
system; mental or
emotional di
sorder; dizziness; loss
of
consciousness; convulsions; or epilepsy?
e. Asthma; tuberculosis; or any disease of the lungs
or re
spiratory system?
f. Hea
rt disease; rheumatic fever; or heart murmur?
g. High blood pressure; heart attack; or chest pain?
h. Stomach or duodenal ulcer; indigestion; or any
dise
ase or disorder of the: stomach;
intestines;
rectum; liver; or gall bladder?
i. Hernia; hemorrhoids; varicose veins;
dise
ase of the blood vessels;
anemia; or other blood di
sorder?
j. Kidney colic or stone; syphilis; or
any disease of the kidney or
bladder?
k. Sugar; album
in; blood; or pus in the
urine
?
l. Deformity; joint disorder; or physical
impairm
ent?
m. Tested positi
ve for exposur
e to the
HIV infection
or been diagnosed as
having ARC or AIDS ca
use by the
HIV infection or other sickness or
condition derived from such
infection?
n. Disease or disorder of the genital;
and/or rep
roductive organs?
o.
Been diagnosed or treated for
exce
ssive use of: alcohol; tobacco;
or habit-formi
ng drug?
2. Are you or any Proposed Insured currently pregnant?
3. Other than the above, have you or any Proposed Insured, within the past 5 years:
a. Had an electrocardiogram; x-ray; or other special
test?
b. Been consulted; treated; or examined by any
physi
cian or practitioner for any rea
son not
previously mentioned?
c. Been operated on, or advised to have any
operation?
d. Had a physical check-up?
e. Been postponed; rated up or
declined for Life; Hospitalization;
Major Medica
l; or Accident and
Sickness Insurance?
f. Made claim for or received benefits
or pen
sion due to any injury or
illness?
4.Name, address and phone number of primary care physician:_________________________________________
___________________________________________________________________________________________
If any question is answered “Yes,” give details below. Also, show name and address of atte
nding physician(s) if
other than listed in 4. above.
Question Person to whom Illness or Nature Date
Physician’s Name and
# it applies of Injury Address
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(add separate sheet if additional space is needed)
Page 2
LRS-9115-0102-FL
AGREEMENT
I represent that to the best of my knowledge and belief that each of the above sta
t
ements an
d answe
rs a
r
e
compl
ete
and
true. I un
derstand
that
the insurance applied for will not become effective until this Application has been
approved by Reliance Standard Life Insurance Company and only in accordance with the provisions of the Policy. I
understand and agree that if I am applying after the expiration of my initial eligibility period, all medical tests
and costs for attending physician reports will be without expense to Reliance Standard Life Insurance
Company and that I will be responsible for paying the expenses, if any.
AUTHORIZATION—I he
reby authorize any licensed physician, me
dical practitioner, hospital, clinic or other medical
or medically related facility, insurance company, organization, institution, person or the Medical Information Bureau
(MIB) to release any information or record(s) on me (us) or my (our) health to be used in determining the acceptability
of my (our) application for insurance. I authorize any such informa
tion or record(s) to be released to Reliance
Standard Life Insura
nce Company or its reinsurers. I also authorize Reliance Standard Life Insurance Company or
its reinsurers to make a brief report of my (our) personal health information to the MIB. This Authorization, or a photographic
copy, shall be binding as the
original and valid for a period not exceeding twelve (12) months from this date. I understand
that I (we) may elect to be interviewed if an investigative consumer report is to be prepared in connection with my (our)
application and that I am (we are) entitled to a copy thereof. I further understand that I am (we are) entitled to receive a
copy of this Authorization upon request.
I acknowledge receipt of the “Notice Regarding Information Practices.”
Any person who knowingly and with intent to injure, defraud, o
r deceive
any insurer files a statement of claim or an
applic
ation containing any false, incomplete of misleading information is guilty of a felony of the third degree.
DATE SIGNED __________ SIGNATURE OF EMPLOYEE/MEMBER _____________________________
DATE SIGNED __________ SIGNATURE OF SPOUSE (if spouse is requesting coverage) _____________
Page 3
LRS-9115-0102-FL
NOTICE REGARDING INFORMATION PRACTICES
In considering this Appli cation, Reliance Standard Life Insurance Company ("we", "us" o r "our") collects certain
information about all proposed insureds ("you" or "your"). The precise information varies according to the amount
and type of coverage yo u apply for. Generally, we seek information about your: (1) age; (2) occu
pation; (3)
physical cond
ition; (4) medical history; (5) hobbies; and (6) other relevant activities.
You are the most important source of information, but we m ay also ve rify or collect information on you or you r
family from: (1) physicians; (2) oth er health care providers; (3) employers; (4) other insurers to whi ch you have
applied; (5) consumer investigative organizations; and (6) the Medical Information Bureau ("MIB").
The MIB is a not-for-profit organization of life insurance companies which operates an information exchange for its
members. This information may alert u s to a ne ed for further investigation, but under MIB rules such information
cannot be u sed: (1) eith er wholly or in part to incre ase the premium for in surance; or (2) to deny issuance of
insurance.
We may collect information by: (1) phone; (2) correspondence; or (3) personal contact.
Information will be treated as confidential. Relia nce Standard Life Insurance Company or its reinsurers may,
however,
with your auth
orization make a brief report to the MIB. If you a pply to another MIB member company for
life or health insurance coverage, or a claim for benefits is submitted to such a company, the MIB, upon request,
will
supply such company with the information in its file. The information suppli
ed to other member companies may
alert them to a need for further investigation.
In some circumstances, however, information may be released to third parties without your authorization (with the
exception of the MIB). These include persons or organizations who are: (1) p erforming business functions for us;
(2) conducting actuarial or scientific studies or audits; or (3) our reinsurers. We or our reinsurers may also release
information to other life insurance companies to whom you apply for life or health insurance coverage, or to whom a
claim for benefits is submitted. Please be assured that although such disclosures may occur, they are not always
or even often made. Whe n a disclo sure is ne cessary, only as much information as i s reasonably necessary to
achieve the intended purpose will be disclosed.
You have the right to acquire and, if necessary, correct any pe rsonal information we or t he MIB collect. Upon
written request to us, we will within 30 days of receipt: (1) inform you of the nature an d substance of the recorded
information; (2) permit personal viewing and copying of the information in our possession; (3) disclose the identities
of those p ersons such information has been disclosed to within the l ast two years; and (4) provide you with
procedures for correction, amendment or deletion of the recorded information. Medical information will be
disclo
sed to a
physician that you choose. You may write to us for a fuller explanation of our information practices.
You may also contact the MIB via its website (www.mib.com) or by telephon e to arran ge for discl osure of any
information it may have o n you. The MIB's toll-fr ee telephone number is 866-692-6901 (TTY 866-346-3642 for
hearing impaired). If you q uestion the accuracy of information in the MIB's file, you may contact the MIB in writing
and seek correction in a ccordance with the p rocedures set fort h in the fed eral Fair Credit Reporting Act. The
address of the MIB's information office is 50 Braintree Hill, Suite 400, Braintree, Massachusetts 02184-8734.
KEEP THIS NOTICE FOR YOUR RECORDS.
Home Office: Chicago, Illinois
Administrative Office: Philadelphia, Pennsylvania
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Completed 20 November 2019

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