Please retain a copy for your records and submit this form to Guardian
Page 3 of 6
Representations of the Proposed Insured(s) and Authorization Please read and sign below.
Part I. Representations of the Proposed Insured
Those parties who sign below hereby represent that the statements and answers to the question(s) are, to the best of the knowledge and belief of the
party signing below, full, complete, true and correctly recorded. Those parties who sign below understand that they will form the basis of any coverage
under the Group Plan for which Evidence of Insurability is required. When used in this Part I, “I” refers to the person applying for insurance signing
Also, it is mutually understood and agreed that (1) the Company reserves the right to request, at its expense (except in the case of a late entrant, it is
not at the Company’s expense), that any proposed insured be examined by an accredited medical examiner selected by the Company; (2) no Group
Insurance will be binding or in force until satisfactory evidence of insurability is submitted, approved by the Company and the required premiums are
received by the Company; and: (a) I am actively at work on a full-time basis (as defined in the Group Plan) for full pay on the date my Group Insurance
becomes effective; otherwise, (b) I become insured on the date I do return to work and satisfy a waiting period (as defined in the Group Plan) of full-time
service; (3) coverage for my dependents will not take effect if a dependent other than a newborn is: (a) confined to the hospital or other health care
facility; or (b) is unable to perform the normal activities of someone of like age and sex; (4) no person, except the President, a Vice President or a
Secretary of the Company, has authority to: (a) determine whether any contract(s) of insurance shall be issued on the basis of the application; (b) waive
or modify any of the provisions of the application or any of the Company’s requirements; (c) bind the Company by any statement or promise pertaining
to any insurance contract(s) issued or to be issued on the basis of the application; or (d) accept any information or representation not contained in the
written application; (5) the employer is hereby named the Proposed Insured’s representative for the purpose of receiving premiums and remitting them
to the Company. In the event the Company receives premiums in excess of the appropriate amount for the coverage provided, the Company will only be
liable for the overpaid premiums plus applicable interest.
For Life Insurance Coverage Only: Material misrepresentations made by the insured relating to that person’s insurability may be used in contesting the
validity of the individual coverage with respect to which such statement was made within the first two years coverage issued based on this Evidence of
Insurability Form is in effect, only if the statement is in a signed writing that is furnished to the insured or the insured’s beneficiary.
For Coverages Other Than Life Insurance: Any misrepresentation or omission, if found to be material, may adversely affect acceptance of the risk,
claims payment or may lead to rescission of any coverage issued based on this Evidence of Insurability Form.
Part II. Authorization to Obtain Information (Medical Records and other information)
I authorize my physician, medical practitioner, hospital, clinic, other health facility, practitioner, mental health professional, pharmacy or pharmacy
benefit manager, laboratory, the MIB, Inc., insurance or reinsurance company, group policyholder, benefit plan administrator, employer, other
organization, institution or person that has any records or knowledge of the Proposed Insured or his/her health, business associate, other person or
organization to release any and all medical and non-medical information in its possession about me, to The Guardian Life Insurance Company of
America or its legal representatives. Medical information means all information in the possession of or derived from providers of health care regarding
the medical history, pharmaceutical history, and all past and present physical, mental condition, or treatment of me. Non-medical information includes
employment history, job duties, and any wage or earnings information. I understand that the information released could contain reference to the
symptoms, evaluation, diagnosis, examination, treatment or prognosis of any mental or physical condition, including psychiatric, and psychological
conditions. I understand that medical and non-medical information that can be released does not include drug and alcohol records and psychotherapy
notes. I understand that a separate authorization is required for these types of medical records.
I understand that Guardian will use the information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an
existing plan. I further understand that if I refuse to sign this authorization, the Company may not be able to process my application. Guardian will not
release any information obtained to any person or organization except to reinsurance companies, the MIB, Inc., or other persons or organizations
performing business or legal services in connection with my application, claim or as may be lawfully permitted or required, or as I may fully authorize. I
understand that any information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be
protected by federal regulations governing privacy (such as the HIPAA Privacy Rule). By my signature below, I authorize The Guardian Life
Insurance Company of America or its reinsurers to make a brief report of my protected health information to MIB, Inc.
I know that I may revoke this authorization in writing, at any time, by sending a written request for revocation to the Guardian Corporate Secretary at 7
Hanover Square, New York, NY 10004-2616. I understand that a revocation is not effective to the extent that the Company and/or any of the entities
listed above has already relied on this authorization, or to the extent that the Company has a legal right to contest a claim under an insurance policy or
to contest the policy itself.
I know that I may request and receive a copy of this authorization.