Fillable Minnesota Life Group Life Insurance Evidence Of Insurability Form (Page 3 of 3) in pdf

EMPLOYER NAME: State of New Mexico

POLICY NUMBER: 34426

AUTHORIZATION

I authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility,

pharmacy benefit manager, or other health care provider that has provided payment, treatment or services to me or on my

behalf to disclose my entire medical record and any other protected health information concerning me to Minnesota Life

Insurance Company, (the Company), and its employees, reinsurers and 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 and the use of alcohol, drugs and tobacco.

I also authorize any person(s), medical practitioner, institution, insurance company or Medical Information Bureau (MIB) to

give any medical or nonmedical information about me including alcohol or drug abuse, to the Company and its reinsurers.

I authorize all said sources, except MIB, to give such information to any agency employed by the Company to collect and

transmit such information. I authorize the Company, or its reinsurers, to make a brief report of my personal health

information to MIB.

This protected health information is to be disclosed under this Authorization so the Company may: 1) underwrite my

application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; 2) obtain

reinsurance; 3) administer claims and determine or fulfill responsibility for coverage and provision of benefits; 4)

administer coverage; and 5) conduct other legally permissible activities that relate to any coverage I have or have applied

for with the Company.

This Authorization shall remain in force for 24 months following the date of my signature below. A copy of this

Authorization is as valid as the original. I understand I am entitled to receive a copy of this Authorization. I understand

that I have the right to revoke this Authorization in writing, at any time, by sending a written request for revocation to the

Company. I understand that a revocation does not apply to any action that was taken in reliance on this Authorization or

to the Company's legal right to contest a claim under an insurance policy or to contest the policy itself. I understand that

there is a possibility of re-disclosure of any information disclosed pursuant to this authorization and that information,

once disclosed, may no longer be protected by federal rules governing privacy and confidentiality. I understand that if I

refuse to sign this Authorization to release my complete medical record, the Company may not be able to process my

application, or if coverage has been issued may not be able to make any benefit payments.

CONSUMER PRIVACY NOTICE

To underwrite your insurance request, the Company may ask for additional personal information, such as an insurance

medical exam; lab tests; medical records from your insurance company, physician or hospital; a report from the Medical

Information Bureau (MIB), a non-profit organization of life insurance companies that exchanges information among its

members. Information about your insurability is confidential. Without your express authorization, the Company or its

reinsurers may send your information to government agencies that regulate insurance; or, without identifying you, to

insurance organizations for statistical studies. If you apply to a MIB member company for life or health insurance, or

submit a benefits claim for benefits to a member company, the MIB, upon request, will supply the member company with

the information in its file. You or your authorized representative have the right to: receive by mail or to copy your personal

information in the Company or MIB files, including the source and who received copies within the past two years; to

correct or amend personal information in these files; to know specific reasons why coverage was not issued as applied for;

and to revoke your authorization at any time. At your written request, within 30 days the Company will explain in writing

how to learn what is in your file, its source, how to correct or amend it or how to learn why coverage was not issued as

applied for. You can send the Company a written statement as to why you disagree. If we correct or amend the

information, we will notify you and anyone who may have received the information. If we do not agree with your statement,

we will notify you and keep your statement in your file.

For further information about your file or your rights,

For information about the MIB, you may contact:

you may contact:

MIB

50 Braintree Hill, Suite 400

Group Division Underwriting

Braintree, MA 02184-8734

Minnesota Life Insurance Company

400 Robert Street North

MIB Telephone: (866) 692-6901

MIB TTY: (866) 346-3642

St. Paul, Minnesota 55101-2098

Website:

Telephone: (800) 872-2214

I have read this Authorization and Consumer Privacy Notice and I understand I can have copies. The answers provided on

this application are representations of the person signing below. The answers given are true and complete. It is

understood that Minnesota Life Insurance Company shall incur no liability because of this application unless and until it is

approved by the Company and the first premium is paid while my health and other conditions affecting my insurability are

as described in this application. I authorize my employer to withdraw premiums from my salary to pay for this coverage. I

understand that false or incorrect answers to the above questions may lead to rescission of coverage. If coverage is

rescinded, an otherwise valid claim will be denied. 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.

Employee name (please print)

Date of birth

Employee signature

Daytime phone number

Evening phone number

Date signed

Spouse/domestic partner name (please print)

Date of birth

Spouse/domestic partner signature

Daytime phone number

Evening phone number

Date signed

12-31468.30

EdF83454 Rev 7-2015

Minnesota Life Group Life Insurance Evidence Of Insurability Form Page 3

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