Fillable Standard Insurance Company Medical History Statement DIRECTIONS FOR (City of Hickory)

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Standard Insurance Company Medical History Statement DIRECTIONS FOR (City of Hickory)

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SI 16119 1 of 4 (6/13)
Standard Insurance Company
Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204
Medical History Statement
Read the Information Practices Notice(s) on page 4. 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 3. Keep a copy for your records, and send the original to Standard Insurance Company at the address given above.
DIRECTIONS FOR APPLYING FOR COVERAGE
APPLICATION INFORMATION
Check the type and provide details on the amount of coverage you are requesting.
Short Term Disability
Long Term Disability + =
Life + =
Dependents Life + =
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Member/Employee
Spouse
Child
Name of Group Group Number Check who is Applying (One per form)
Member/Employee Name Birth Date (Mo/Day/Year) Date Hired (Mo/Day/Year)
Occupation Salary
Social Security Number
Member/Employee Identifi cation No.
MEMBER/EMPLOYEE INFORMATION
Applicant’s Name (Person to be insured) Email Address
Street Address City State/Province ZIP/Postal Code
Sex Birth Date (Mo/Day/Year) Birthplace
Social Security Number
Work Phone ( )
Home Phone ( )
M F
APPLICANT INFORMATION
PHYSICIAN INFORMATION
(Physician name or medical facility with Applicant’s complete medical records—provide name and full mailing address)
Doctor First Name Doctor Last Name
Clinic Name Doctor Phone
Doctor Address City State/Province ZIP/Postal Code
Date Last Consulted
Reason Last Consulted
Reset
SI 16119 2 of 4 (6/13)
Applicant Name Social Security Number
MEDICAL HISTORY STATEMENT QUESTIONS
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 been absent from work for a period of 5 or more consecutive days during the last 2 years due to any sickness,
surgery, injury, mental or emotional condition?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
2. Has a medical professional 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 disorder, or digestive system disorder?
. . . . . . . . . . . . . .
Yes
No
B. Multiple sclerosis, epilepsy, stroke, paralysis, numbness, visual disturbance, deafness, or another neurological
or muscle disorder?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
C. Cancer (malignancy or growth), leukemia, lymphoma, chronic anemia, or blood clotting
(thrombophlebitis, pulmonary embolism)?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
D. Cardiovascular disease, heart ailment, arteriosclerosis, chest pain, high blood pressure, heart murmur, valve,
circulatory or vascular disorder?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
E. Emphysema, asthma, chronic bronchitis, sleep apnea, or other lung disease?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
F. Lupus, scleroderma, vasculitis, connective tissue disease, or other immune system disorder not related to
Human Immunodefi 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, or arthritic conditions?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
H. Endocrine (including thyroid or adrenal), diabetes?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
I. Drug, alcohol or nicotine use or abuse, or have you used drugs, alcohol or nicotine in a manner that resulted in
you having to obtain advice, counseling or treatment?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
J. Psychiatric or mental condition, depression, adjustment disorder, affective disorder, or obsessive-compulsive disorder?
. . .
Yes
No
3. Has a medical professional ever diagnosed you as having or prescribed medication to you for Acquired Immune
Defi ciency Syndrome (AIDS) or AIDS Related Complex (ARC) or HIV antibodies?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
4. During the past fi ve years have you been in a hospital or other institution for observation, rest, diagnosis, or
treatment of any disease, disorder, condition or injury?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5. Do you plan any operation or visit to a doctor or practitioner for an existing physical or mental condition, illness,
injury, surgery or pregnancy?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
6. Do you currently have any disorder, condition or disease, or are you currently taking medication prescribed by a
medical or other practitioner for any disorder, condition (including pregnancy) or disease other than cold or
allergies not disclosed above?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Height ______________________________ Weight
___________________________________________
DETAILS OF ANY “YES” ANSWERS ABOVE
Include diagnosis, start and end dates, duration, type and frequency of treatment, hospitalization,
physician visits, cause, location of disorder, residuals, acute or chronic status, work loss, and operations.
Question # Diagnosis/Description Month/Year Details/Current Status Physicians Consulted, City and State
SI 16119 3 of 4 (6/13)
• I represent that the statements contained herein, including those made in response to the Medical History Statement questions and any supplemental
information, 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 (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 Defi 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 authorize The Standard to 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 benefi 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 benefi ciary designation on fi le with my plan administrator, I understand the
designation(s) on fi le will also apply to any approved amounts. If I have no benefi ciary designation(s) on fi le or I wish to change the name of the
current benefi 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 Fraud Notice (if applicable), and I have made a copy of this
Medical History Statement.
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.
Signature of Applicant (or Member/Employee for Dependent Child)
Date
Applicant Name Social Security Number
SI 16119 4 of 4 (6/13)
•
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 confi dential. Standard Insurance Company or its reinsurers may, however, make a
brief report thereon to MIB, a not-for-profi 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 benefi ts is submitted to such a company, MIB, upon request, will supply such company with the information in its fi le.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your fi le. Please contact MIB at 866-692-
6901 (TTY 866-346-3642). If you question the accuracy of information in MIB’s fi 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 offi ce is: 50 Braintree Hill Park, Suite
400, Braintree, Massachusetts 02184-8734.
Standard Insurance Company may release information in its fi le to its reinsurers, and Standard Insurance Company, or its reinsurers, may
release information in its fi 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 benefi 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 confi 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 fi 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 justifi 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
• ARKANSAS, MAINE, OHIO: Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive
an insurance company, or other person, fi les a statement containing false or misleading information concerning any fact material hereto
commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed
a felony and substantial fi nes may be imposed.
• COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fi nes, denial of insurance, and civil damages.
Any insurance company or agent of an insurance company who kindly provides false, incomplete, or misleading facts or information to the
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or
award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
• DISTRICT OF COLUMBIA: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any
other person. Penalties include imprisonment and/or fi nes. In addition, an insurer may deny insurance benefi ts if false information materially
related to a claim was provided by the applicant.
• KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.
• LOUISIANA, NEW MEXICO: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefi t
or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and
confi nement in prison.
• MARYLAND, RHODE ISLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefi t
or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and
confi nement in prison.
• NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
• NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance
or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent act, which is a crime, and shall be subject to a civil penalty not to exceed fi ve thousand dollars and the
stated value of the claim for each such violation.
• PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
• PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or fi le,
assist or abet in the fi ling of a fraudulent claim to obtain payment of a loss or any other benefi t, or fi les more than one claim for the same loss
or damage, commits a felony and if found guilty shall be punished for each violation with a fi ne of no less than fi ve thousand dollars ($5,000),
not to exceed ten thousand dollars ($10,000); or imprisoned for a fi xed term of three (3) years, or both. If aggravating circumstances exist,
the fi xed jail term may be increased to a maximum of fi ve (5) years; if mitigating circumstances are present, the jail term may be reduced to
a minimum of two (2) years.
• TENNESSEE, VIRGINIA, WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fi nes, and denial of insurance benefi ts.
FRAUD NOTICE
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Standard Insurance Company Medical History Statement DIRECTIONS FOR (City of Hickory)

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Completed 23 January 2021

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