NOTICE OF INSURANCE INFORMATION PRACTICES
In the course of properly underwriting and administering your insurance coverage, we will rely heavily on information provided by you. We
may also seek information from others, such as medical professionals who have treated you. In some cases, we may ask a consumer
reporting agency to collect information and submit an investigative consumer report to us. You have the right to request to be interviewed
in connection with the preparation of that report. You may receive a copy of the report upon request.
You have the right to be told about, and to see and copy if you wish, items of personal information about you which appear in our files,
including information contained in investigative consumer reports. You also have the right to seek correction of information you believe to
be inaccurate.
The above is a general description of our information practices. If you would like to receive a more detailed explanation of those practices,
please send your request to the chief underwriter, P.O. Box 1650, Little Rock, AR 72203
FEDERAL FAIR CREDIT REPORTING ACT NOTICE
In connection with your application for insurance, an investigative consumer report may be prepared whereby information is obtained
through personal interviews with your family, friends, neighbors, business associates, financial sources, or others with whom you are
acquainted. This inquiry includes information as to your character and general reputation. If an investigative consumer report is prepared in
connection with your application, you may receive a copy of that report upon written request to the Company.
USAble Life
P.O. Box 1650 y Little Rock, Arkansas 72203
EVIDENCE OF INSURABILITY (Please Print)
A completed Enrollment Form must accompany this form.
SECTION 1 –Completed By Employer
Group Name
Date of Hire Telephone # (include area code) Group Number
Amount of Insurance Applying for:
Employee Life: $ Dependent Life $ Disability $ Other:
Employee’s Annual Salary
SECTION 2 – Completed by Employee
Vol. Group Term Life Amount over Guarantee Issue Late Enrollee
Name (First, MI, Last)
Social Security No.
Home Address
City State Zip County
Date of Birth Birth State or Country
Gender
M F
Height (ft-in.) Weight (lbs.) Work Phone
Home Phone
Spouse & Children Information – Complete if Applying for Dependent’s Coverage.
Person Proposed for Insurance
Show first, middle, last name
Occupation
Date of Birth & Place
Height Weight
Marital
Status
Sex
Month Day Year
State or
Country
(Spouse)
(Child)
(Child)
(Child)
(Child)
Spouse’s Social Security No.:
Spouse’s Work Telephone #:
SECTION 3 – Insurability Questionnaire Yes No
1. Has anyone to be covered used any tobacco products in the past year?
2. Does anyone to be covered have any condition for which consultation or treatment is contemplated or has been
advised?
3. Has anyone to be covered been hospitalized for any reason during the past five (5) years?
4. Has anyone to be covered consulted a physician in the past one (1) year for any reason?
5. Has anyone to be covered ever been diagnosed or treated by a member of the medical profession for:
a. Cancer, cancer related disease or benign tumor?
b. Disease of the heart or blood vessels, or had a
stroke?
c. Kidney disease or diabetes?
d. Alcohol or drug abuse?
e. Lung, asthma, liver or blood disorder?
Yes No
f. Emotional, nervous system, eating disorder, or
mental health problems?
g. Ulcer, stomach or digestive disorder?
h. Arthritis, back, bones or joint disorder?
i. Bladder, urinary system or reproductive organs
disorder?
Yes
No
6. Has anyone to be covered ever been diagnosed or treated by a member of the medical profession for: Acquired
Immunodeficiency Syndrome ("AIDS") or AIDS Related Complex, or Human Immunodeficiency Virus ("HIV")?
7. Has anyone to be covered ever been diagnosed or treated by a member of the medical profession for hypertension
(high blood pressure) or high cholesterol? If yes, list name of person(s), medications taken, medication dosage, last
two blood pressure readings, and/or last two cholesterol readings in Section 4.
8. Is anyone to be covered currently taking medication(s)? If yes, list name of person, reasons, medications and
dosage in Section 4.
9. Has anyone to be covered ever had any impairments, diseases or illnesses not covered in questions 2 – 8?
10a. Are you now pregnant?
Yes No
10b. Have you ever had an ectopic pregnancy, a problem pregnancy, a
miscarriage, a problem delivery, a therapeutic abortion, or a Cesarean section?
11. Are you actively at work on the date of this application and have you been actively at work for the 31 days prior to
such date? If No, give full details in Section 4.
12. Names, addresses, and phone numbers of the personal physicians of all applicants:
___________________________________________________________________________________________________
SECTION 4 – Give Details to “Yes” answers to questions 2 through 10 include dates of treatment: Separate Sheet Attached
Ques. No.&
Individual
Illness/Reason for Checkup or Medication & Dosage or
Doctor’s Treatment/Consultation
Date & Duration
Full Name, Complete Address and Telephone Number
of Doctors & Hospitals
Be Sure to Read the Important Disclosures and sign on Page 2/Reverse
EOI (1-13)
