Fillable Symetra-evidence-insurability - LGC_2106TX_1012

Fill Online, Printable, Fillable, Blank Symetra-evidence-insurability - LGC_2106TX_1012 Form

Use Fill to complete blank online SAINT LOUIS UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Symetra-evidence-insurability - LGC_2106TX_1012

On average this form takes 46 minutes to complete

The Symetra-evidence-insurability - LGC_2106TX_1012 form is 16 pages long and contains:

  • 0 signatures
  • 50 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Saint Louis University

BROWSE SAINT LOUIS UNIVERSITY 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
 
Symetra
®
is a registered service mark of Symetra Life Insurance Company.
LGC-2106 10/12
Evidence of Insurability
for Group Coverage
Instructions
Employer/Policyholder Please complete Page 2 and provide to the employee/applicant to complete.
Employee/Applicant Please complete page 3, sign and date page 4 and an "Authorization for Release of Medical
Information" form. If applying for spouse coverage, have your spouse complete page 6,
sign and date page 7 and an "Authorization for Release of Medical Information" form.
Return to Symetra for processing.
Two copies of the 'Authorization for Release of Medical Information' form are included in the
back of this packet. One for you and one for your spouse, if applicable.
Completed forms can be mailed or faxed to:
Symetra Life Insurance Company
PO Box 34690
Seattle, WA 98124-1690
Fax: 1-866-348-0058
Symetra Life Insurance Company | Benefits Division | 777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135 | www.symetra.com
Mailing Address: PO Box 34690 | Seattle, WA 98124-1690 | Phone 1-800-426-7784 | TTY/TDD 1-800-833-6388
Comments
LGC-2106 10/12 Page 2 of 8
Symetra Life Insurance Company
Benefits Division
7
77 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135
Mailing Address: PO Box 34690 | Seattle, WA 98124-1690
Phone 1-800-426-7784 | TTY/TDD 1-800-833-6388
Fax completed forms to: 1-866-348-0058
EVIDENCE OF INSURABILITY FOR GROUP COVERAGE
Policyholders: Completely fill out Sections 1 – 3 and forward to the applicant to complete, sign and return to Symetra.
Section 1: Group Plan Details (
to be completed by Policyholder)
Company name (policyholder) Policy number
Division or associated company (if applicable)
Company mailing address (street, city, state, zip code)
Benefits contact name (first, last)
Benefits contact email address Benefits contact phone (include area code)
Section 2: Applicant Details (to be completed by Policyholder)
Name of applicant Date of hire (mm/dd/yyyy)
Class Basic Annual Earnings*
*As described in the group policy
Section 3: Coverages Requested (to be completed by Policyholder) Check all that apply
Coverage (Check all that apply)
Current amount of coverage
(including GI** amount)
Additional coverage
requested
Total coverage
amount
(Example for Life Policies)
$50,000 $300,000 $350,000
Applicant: Basic Life
Applicant: Supplemental or Voluntary Life
Spouse: Basic Life
Spouse: Supplemental or Voluntary Life
Applicant: Short Term Disability Yes No
Applicant: Voluntary Short Term Disability Yes No
Applicant: Long Term Disability Yes No
Applicant: Voluntary Long Term Disability Yes No
**Guarantee Issue (GI) is the maximum amount of coverage defined by the group policy that does not require evidence of insurability.
Saint Louis University
3545 Lindell Blvd, Saint Louis, MO 63103
$0
$0
$0
$0
LGC-2106 10/12 Page 3 of 8
Section 4: Applicant Information (to be completed by applicant)
Applicant name (first, last) Gender
Male Female
Applicant address (street, city, state, zip code)
Date of birth Height Weight Driver License number Email address
State of birth Day phone (include area code) Evening phone (include area code)
How may we best contact you?
Symetra offers secure e-mail for the quickest turnaround time Mail Email Day phone Evening phone
Full name, address and phone of your personal physician
Section 5: Applicant Health Information (to be completed by applicant)
The following health questions must be answered fully and truthfully to the best of your knowledge and belief. If any
misstatements or omissions are made, they may be the basis for later rescission of your insurance coverage. Rescission voids
your coverage and claims will not be paid.
1. Are you pregnant? Yes No If yes, please give details in the Health Information Section including due date.
2. In the past ten years, or as indicated below, have you been treated for, or been diagnosed with by a member of the medical
profession as having any of the following conditions? If yes, please check the box and provide details in Section 6.
a
)
Heart Disease or Disorder
b)
Bipolar Disorder, Major Depressive Disorder, or Schizophrenia
c)
Alcoholism and/or Drug Use
d)
Acquired Immune Deficiency Syndrome (AIDS) or Human
Immunodeficiency Virus (HIV) Infection/Disease, or tested
Positive to the AIDS virus (HIV)
e
)
Stroke, Paral
y
sis
f)
Multiple Sclerosis, ALS (Lou Gehrig’s Disease)
g)
Type I/Insulin-Dependent Diabetes
h)
Grand Mal Epilepsy or Generalized Seizures
i)
Hepatitis B or C
j)
Cirrhosis of the liver
3. In the past ten years, or as indicated below, have you been treated for, or been diagnosed with by a member of the medical
profession as having any of the following conditions? If yes, please check the box and provide details in Section 6.
k
)
Non-Insulin Dependent/ T
y
pe II Diabetes
l) Mental & Nervous Disorder; Depression/Anxiety
m)
Brain or Central Nervous System disorder; Parkinsonism,
Absence Seizures/Petit Mal Epilepsy
n)
Liver Disorder
o)
Kidney Disorder
p
)
Blood Disorder
q)
Stomach, Abdominal, Intestinal Disorder
r)
Bone, Joint, Connective Tissue Disorder
s)
Cancer, Tumors
t)
Gland Disorder
u)
Lungs, Respiratory Disorder
4. Have you consulted, been advised or been examined by any healthcare provider for any other medical reason within the
last ten years, or as indicated above?
Yes No
If yes, please indicate condition and provide details in the Health Information Section.
Section 6: Applicant Health Information (to be completed by the applicable person)
Question
# or Letter
Details of Yes answers
Onset
Mo. Yr.
Duration Degree of recovery
Name/address/phone of
attending physician
Please list all your medications
Medication Dosage/Frequency
What condition is treated
with this medication?
Onset
Mo. Yr.
LGC-2106 10/12 Page 4 of 8
By signing below, I agree that all statements and answers recorded on this Application are true and complete to the best
of my knowledge and belief, and shall form a part of any policy issued. I also agree that I have read and understand the fraud warning
on the following page which applies to me.
Signature of applicant Date
Print name
Remember to complete an "Authorization for Release of Medical Information" form to send to Symetra with this package.
Applicant's copy
Disclosure Notice to Applicants for Insurance
This brief description of our underwriting process is designed to help you to understand how an application for insurance is
handled, the type and sources of information we may collect about you, the circumstances under which we may disclose that
information to others and your right to learn the nature and substance of that information upon written request. Your medical
history and current physical condition, which is obtained from various sources, are factors, which are considered in
determining your insurability.
Sources of Information:
Your application, including the medical history, is a primary source of information in the evaluation process. We may also
ask for a report from your doctor, hospital, pharmacy, pharmacy benefit manager or another insurance company. When we do
so, we use the authorization form you sign with your application. It is sometimes necessary that we ask you to take a physical
examination or other special tests such as an electrocardiogram and/or blood test.
Disclosure to Others:
Personal information obtained about you during the underwriting process is confidential and will not be disclosed to other
persons or organizations without your written authorization except to the extent necessary for the conduct of our business.
Examples of situations where we share information about you are as follows:
1. The agent may retain a copy of your application. If reinsurance is required, the reinsurance company would have
access to our application file.
2. We may release information to another life insurance company to whom you have applied for life or health
insurance or to whom you have submitted a claim for benefits, if you have authorized them to obtain this
information.
3. We would disclose information to government regulatory officials, law enforcement authorities and others where
required by law.
Disclosure to You:
If an adverse underwriting decision is made, we will notify you of the reason(s) for that decision and the source of the
information upon which our action is based. Medical record information, however, will be given only to a licensed physician
of your choice.*
Symetra Life Insurance Company respects your right to the privacy of your personal information. This notice is provided to
you to help you understand that information, which is obtained, is treated in a confidential manner. You have a right of access
and correction with respect to all personal information collected. Upon written request, we will provide you with a more
detailed description of our information practices and your rights of access and correction.
*For residents of Louisiana and Massachusetts only:
Medical record information will be given to a medical professional designated by you and licensed to provide the kind of
medical care in question or, if you prefer, to you directly. Mental health record information will be given directly to you only
with the approval or the professional who has treatment responsibility for the condition in question.
LGC-2106 10/12 Page 5 of 8
Please read the following notice that we are required by law to give to you.
For all states not named
: Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
AR, LA, RI, WV
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ: For your protection Arizona law requires the following statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
CA: For your protection California law requires the following to appear hereon: Any person who knowingly presents a false or fraudulent
claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
CO
: 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, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
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.
DE
: Any person who knowingly, and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.
DC
: WARNING: 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 fines. In addition, an insurer may deny insurance benefits if false information materially related
to a claim was provided by the applicant.
FL
: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
ME
: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MD
: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NH
: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false,
incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
NJ
: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
NM
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NY
: The following applies to health insurance only: Any person who knowingly and with intent to defraud any insurance company or other
person files 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 shall also be subject to
a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OK
: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PA
: Any person who knowingly and with intent to defraud any insurance company or other person files 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.
TN, VA, WA
: 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, fines and denial of insurance benefits.
TX
: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
LGC-2106 10/12 Page 6 of 8
Section 7: Spouse/Domestic Partner/Civil Union Partner Information (to be completed by the Spouse or Domestic Partner/Civil Union Partner (if applicable))
Spouse/Domestic Partner name (first, last) Gender
Male Female
Address (street, city, state, zip code)
Date of birth Height Weight Drivers license number Email address
State of birth Day phone (include area code) Evening phone (include area code)
How may we best contact you?
Symetra offers secure e-mail for the quickest turnaround time Mail Email Day phone Evening phone
Full name, address and phone of your personal physician
Section 8: Spouse/Domestic Partner/Civil Union Partner Health Information (to be completed by the applicable person)
The following health questions must be answered fully and truthfully to the best of your knowledge and belief. If any
misstatements or omissions are made, they may be the basis for later rescission of your insurance coverage. Rescission voids
your coverage and claims will not be paid.
1. Are you pregnant? Yes No If yes, please give details in the Health Information Section including due date.
2. In the past ten years, or as indicated below, have you been treated for, or been diagnosed with by a member of the medical
profession as having any of the following conditions? If yes, please check the box and provide details in Section 9.
a
)
Heart Disease or Disorder
b)
Bipolar Disorder, Major Depressive Disorder, or Schizophrenia
c)
Alcoholism and/or Drug Use
d)
Acquired Immune Deficiency Syndrome (AIDS) or Human
Immunodeficiency Virus (HIV) Infection/Disease, or tested
Positive to the AIDS virus (HIV)
e
)
Stroke, Paral
y
sis
f)
Multiple Sclerosis, ALS (Lou Gehrig’s Disease)
g)
Type I/Insulin-Dependent Diabetes
h)
Grand Mal Epilepsy or Generalized Seizures
i)
Hepatitis B or C
j)
Cirrhosis of the liver
3. In the past ten years, or as indicated below, have you been treated for, or been diagnosed with by a member of the medical
profession as having any of the following conditions? If yes, please check the box and provide details in Section 9.
k
)
Non-Insulin Dependent/ T
y
pe II Diabetes
l) Mental & Nervous Disorder; Depression/Anxiety
m)
Brain or Central Nervous System disorder; Parkinsonism,
Absence Seizures/Petit Mal Epilepsy
n)
Liver Disorder
o)
Kidney Disorder
p
)
Blood Disorder
q)
Stomach, Abdominal, Intestinal Disorder
r)
Bone, Joint, Connective Tissue Disorder
s)
Cancer, Tumors
t)
Gland Disorder
u)
Lungs, Respiratory Disorder
4. Have you consulted, been advised or been examined by any healthcare provider for any other medical reason within the
last ten years, or as indicated above?
Yes No
If yes, please indicate condition and provide details in the Health Information Section.
Section 9: Spouse/Domestic Partner/Civil Union Partner Health Information (to be completed by the applicable person)
Question
# or Letter
Details of Yes answers
Onset
Mo. Yr.
Duration Degree of recovery
Name/address/phone of
attending physician
Please list all your medications
Medication Dosage/Frequency
What condition is treated
with this medication?
Onset
Mo. Yr.
LGC-2106 10/12 Page 7 of 8
By signing below, I agree that all statements and answers recorded on this Application are true and complete to the best
of my knowledge and belief, and shall form a part of any policy issued. I also agree that I have read and understand the fraud warning
on the following page which applies to me.
Signature of Spouse/Domestic Partner (if applicable) Date
Print name
Remember to complete an "Authorization for Release of Medical Information" form to send to Symetra with this package.
Applicant's copy
Disclosure Notice to Applicants for Insurance
This brief description of our underwriting process is designed to help you to understand how an application for insurance is
handled, the type and sources of information we may collect about you, the circumstances under which we may disclose that
information to others and your right to learn the nature and substance of that information upon written request. Your medical
history and current physical condition, which is obtained from various sources, are factors, which are considered in
determining your insurability.
Sources of Information:
Your application, including the medical history, is a primary source of information in the evaluation process. We may also
ask for a report from your doctor, hospital, pharmacy, pharmacy benefit manager or another insurance company. When we do
so, we use the authorization form you sign with your application. It is sometimes necessary that we ask you to take a physical
examination or other special tests such as an electrocardiogram and/or blood test.
Disclosure to Others:
Personal information obtained about you during the underwriting process is confidential and will not be disclosed to other
persons or organizations without your written authorization except to the extent necessary for the conduct of our business.
Examples of situations where we share information about you are as follows:
1. The agent may retain a copy of your application. If reinsurance is required, the reinsurance company would have
access to our application file.
2. We may release information to another life insurance company to whom you have applied for life or health
insurance or to whom you have submitted a claim for benefits, if you have authorized them to obtain this
information.
3. We would disclose information to government regulatory officials, law enforcement authorities and others where
required by law.
Disclosure to You:
If an adverse underwriting decision is made, we will notify you of the reason(s) for that decision and the source of the
information upon which our action is based. Medical record information, however, will be given only to a licensed physician
of your choice.*
Symetra Life Insurance Company respects your right to the privacy of your personal information. This notice is provided to
you to help you understand that information, which is obtained, is treated in a confidential manner. You have a right of access
and correction with respect to all personal information collected. Upon written request, we will provide you with a more
detailed description of our information practices and your rights of access and correction.
*For residents of Louisiana and Massachusetts only:
Medical record information will be given to a medical professional designated by you and licensed to provide the kind of
medical care in question or, if you prefer, to you directly. Mental health record information will be given directly to you only
with the approval or the professional who has treatment responsibility for the condition in question.
LGC-2106 10/12 Page 8 of 8
Please read the following notice that we are required by law to give to you.
For all states not named
: Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any
combination thereof.
AR, LA, RI, WV
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
AZ: For your protection Arizona law requires the following statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
CA: For your protection California law requires the following to appear hereon: Any person who knowingly presents a false or fraudulent
claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
CO
: 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, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
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.
DE
: Any person who knowingly, and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.
DC
: WARNING: 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 fines. In addition, an insurer may deny insurance benefits if false information materially related
to a claim was provided by the applicant.
FL
: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the third degree.
ME
: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MD
: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NH
: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false,
incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
NJ
: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil
penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
NM
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NY
: The following applies to health insurance only: Any person who knowingly and with intent to defraud any insurance company or other
person files 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 shall also be subject to
a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OK
: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PA
: Any person who knowingly and with intent to defraud any insurance company or other person files 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.
TN, VA, WA
: 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, fines and denial of insurance benefits.
TX
: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
Symetra
®
is a registered service mark of Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004.
Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of
First Symetra National Life Insurance Company of New York, 260 Madison Avenue 8th Floor, New York, NY 10016.
LB-85/EOI 4/13
Symetra Life Insurance Company
PO Box 34690 | Seattle, WA 98124-1690
Phone: 1-800-426-7784 | Fax: 1-866-348-0058 | TTY/TDD 1-800-833-6388
Note: We will accept an authorization form preferred by your provider’s office in place of this authorization form.
SYMETRA LIFE INSURANCE COMPANY
Authorization for Release of Medical Information
Group Life Policy Number: __________________________
Name of insured/patient (please type or print): _________________________________________ Date of birth: _________________
I authorize any physician, health care professional, hospital, clinic, medical facility, laboratory, pharmacy or pharmacy benefit
manager, other health care provider, insurance company, or government agency that has provided treatment, services, or payment
to me or on my behalf (“My Providers”) to disclose my entire medical record, medications prescribed, prescription history, and
any other protected health information concerning me to Symetra Life Insurance Company, its employees, agents, or
representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and
sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness, excluding
psychotherapy notes, and the use of alcohol, drugs, and tobacco.
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 physician, health care professional, hospital, clinic, medical facility, or other health care
provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Symetra Life Insurance Company may:
1) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 2) administer coverage;
3) obtain reinsurance; and 4) conduct other legally permissible activities that relate to any coverage I have or have applied for with
Symetra Life Insurance Company.
This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization
is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by providing
written notification to Symetra Life Insurance Company. I understand that a revocation is not effective to the extent that any of
My Providers have already relied on this Authorization to disclose information about me or to the extent that Symetra Life
Insurance Company has a legal right to contest a claim under an insurance policy. I understand that any information that is
disclosed pursuant to this authorization is no longer covered by federal rules governing privacy and confidentiality of health
information, but it will not be redisclosed by Symetra Life Insurance Company except as authorized by me or as required by law.
This Authorization complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
I understand that if I refuse to sign this authorization to release my complete medical record, Symetra Life Insurance Company
may not be able to process my application, continue my coverage, or make any benefit payments. I understand that any
authorized representative or I will receive a copy of this authorization upon request.
________________________________________________________________ ___________________________________
Signature of Insured/Patient or Personal Representative Date
________________________________________________________________
Description of Personal Representative’s Authority or Relationship to Patient
24-000110-00
Symetra
®
is a registered service mark of Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004.
Symetra Life Insurance Company, not a licensed insurer in New York, is the parent company of
First Symetra National Life Insurance Company of New York, 260 Madison Avenue 8th Floor, New York, NY 10016.
LB-85/EOI 4/13
Symetra Life Insurance Company
PO Box 34690 | Seattle, WA 98124-1690
Phone: 1-800-426-7784 | Fax: 1-866-348-0058 | TTY/TDD 1-800-833-6388
Note: We will accept an authorization form preferred by your provider’s office in place of this authorization form.
SYMETRA LIFE INSURANCE COMPANY
Authorization for Release of Medical Information
Group Life Policy Number: __________________________
Name of insured/patient (please type or print): _________________________________________ Date of birth: _________________
I authorize any physician, health care professional, hospital, clinic, medical facility, laboratory, pharmacy or pharmacy benefit
manager, other health care provider, insurance company, or government agency that has provided treatment, services, or payment
to me or on my behalf (“My Providers”) to disclose my entire medical record, medications prescribed, prescription history, and
any other protected health information concerning me to Symetra Life Insurance Company, its employees, agents, or
representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and
sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental illness, excluding
psychotherapy notes, and the use of alcohol, drugs, and tobacco.
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 physician, health care professional, hospital, clinic, medical facility, or other health care
provider to release and disclose my entire medical record without restriction.
This protected health information is to be disclosed under this Authorization so that Symetra Life Insurance Company may:
1) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 2) administer coverage;
3) obtain reinsurance; and 4) conduct other legally permissible activities that relate to any coverage I have or have applied for with
Symetra Life Insurance Company.
This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization
is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by providing
written notification to Symetra Life Insurance Company. I understand that a revocation is not effective to the extent that any of
My Providers have already relied on this Authorization to disclose information about me or to the extent that Symetra Life
Insurance Company has a legal right to contest a claim under an insurance policy. I understand that any information that is
disclosed pursuant to this authorization is no longer covered by federal rules governing privacy and confidentiality of health
information, but it will not be redisclosed by Symetra Life Insurance Company except as authorized by me or as required by law.
This Authorization complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
I understand that if I refuse to sign this authorization to release my complete medical record, Symetra Life Insurance Company
may not be able to process my application, continue my coverage, or make any benefit payments. I understand that any
authorized representative or I will receive a copy of this authorization upon request.
________________________________________________________________ ___________________________________
Signature of Insured/Patient or Personal Representative Date
________________________________________________________________
Description of Personal Representative’s Authority or Relationship to Patient
24-000110-00
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Symetra-evidence-insurability - LGC_2106TX_1012

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document