Evidence Of Insurability Form
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1
2BOSTON MUTUAL LIFE INSURANCE COMPANY
120 Royall Street
Canton, MA 02021
1-800-669-2668 Ext. 473
•
E V I D E N C E O F I N S U R A B I L I T Y F O R M F O R I N S U R A N C E
To be completed for all proposed insureds who are applying for more than the guaranteed issue limit or are completing
the form 31 or more days from the date that the proposed insureds became eligible.
I MPO RTA N T
Refer to the Group Policy for
PLEASE COMPLETE IN FULL
types of coverage available and
Submit with completed
eligible amounts of insurance
Enrollment form.
EMPLOYER SECTION
Group #
Div. #
Employer/Group Name
Social Security #
Employee Name
(Last, First, Middle Initial)
Telephone #
Address
PROPOSED INSURED(S)
Name
Relationship
Date of Birth
Height
Weight
REASON
NEW
CHANGE
Late Applicant
Increase in Coverage
Applying for Coverage in Excess of the
Adding Spouse
Guaranteed Amount
Increasing Spouse
Applying for Supplemental Coverage
Adding Dependent Child(ren)
Other
Other
APPLYING FOR . . .
YOU
LIFE
AD&D
VOLUNTARY LIFE
VOLUNTARY AD&D
Current Insurance
Additional Insurance Requested
Total New Coverage
Short Term Disability
$
Weekly Benefit
Long Term Disability
$
Other
$
Monthly Benefit
YOUR SPOUSE
LIFE
AD&D
VOLUNTARY LIFE
VOLUNTARY AD&D
Current Insurance
Additional Insurance Requested
Total New Coverage
Other
$
GRP- EVID - 6/03
220-004 V A 6/03
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