EVIDENCE OF INSURABILITY FORM
Life Insurance Company of North America (LINA)
a Cigna Company (herein called the Insurance Company)
or info and customer service call 1-
6
-6
7-
6
.
• The applicant must sign and date this form.
• This form cannot be considered unless received within 30 days of the date it is dated.
Important: Please enter all dates in mm/dd/yyyy format. Please print (preferably in black ink).
EMPLOYER USE (MANDATORY DATA NEEDED): In order to process this application, the employer must complete this information.
EMPLOYER
County of Travis Policy FLX-964189
CLASS
LOCATION/PAYCODE #
DATE OF HIRE ANNUAL SALARY VERIFIED BY
REASON FOR REQUEST: NEW HIRE INITIAL ENROLLMENT EVENT ONGOING ENROLLMENT EVENT LATE ENTRANT
VOLUNTARY EMPLOYEE VOLUNTARY SPOUSE/DOMESTIC PARTNER
NEW COVERAGE (TOTAL)
CURRENT COVERAGE
GUARANTEED COVERAGE PORTION OF REQUESTED INCREASE
AMOUNT SUBJECT TO MEDICAL EVIDENCE
EMPLOYEE SECTION
Mr. Mrs. Ms. (Check One)
Employee Name
Social Security # Birthdate
Address City State Zip
Work Phone Home Phone Employee ID # Sex: M F
In order to confirm your election, please provide your signature: Date
COMPLETE IF ELECTING SPOUSE/DOMESTIC PARTNER COVERAGE
I am currently married and my date of marriage is
Spouse/Domestic
Partner Name (First) (Last) Social Security #
Birthdate
Sex: M F
IMPORTANT
Please complete each section that follows if it is needed.
Read the Agreements and Authorization. Sign and date the form in the space provided.
Complete the employee and spouse/domestic partner info in this section if you (i.e., the Employee) or your spouse/domestic partner are applying for Life Insurance that is greater than
the guaranteed amount or are applying for Life Insurance more than 31 days after you were eligible for the insurance.
Height and Weight Information
Employee Spouse/Domestic Partner
Height ft in Weight lbs Height ft in Weight lbs
PHYSICIAN SECTION
Employee Physician Name Phone No.
Street Address City State Zip
Spouse/Domestic Partner Physician Name Phone No.
Street Address City State Zip
Please indicate your answers for each question by checking the Yes or No box for the question.
SECTION A
Within the last 5 years has the proposed insured been:
• diagnosed with any of the conditions shown in items A through J below,
• told by a medical professional he/she has or may have any of the conditions shown in items A through J below,
• or been treated b
a medical
rofessional for an
of the conditions shown in items A throu
h
below?
Employee
Yes No
Spouse
Dom. Part.
Yes No
. High blood pressure, heart attack, chest pain or Angina, a heart murmur, poor circulation or any other condition affectin
the heart or
circulatory system?
B. Diabetes, glandular condition, Hepatitis, or any condition affecting the esophagus, stomach, intestines, liver or pancreas?
C.
sthma, Chronic Bronchitis, Emphysema, or any other condition affecting the lungs or respiratory tract?
D.
ny condition affecting the kidneys, urinary tract, prostate gland or reproductive system?
E. HIV infection, AIDS, or any other condition affecting the immune system or lymph nodes?
F. Stroke, Transient Ischemic Attack (TIA), Alzheimer’s disease, paralysis, Epilepsy, fainting, seizures, headaches, or other condition affecting
the nervous system?
G.
nemia or any other condition affecting the blood, Lupus, Arthritis, deformity or loss of limb?
H.
nxiety, Depression, Bipolar Disorder, or any other mental disorder or condition?
I. Cancer, Tumor, Leukemia, Hodgkin’s Disease, Polyps or Mole?
.
lcohol or drug abuse or dependency?
Fold and staple to conceal health questions. Return application to your employer. Be sure to make a copy for your own records.
TL-009320 (TX)
8/2015
