Evidence Of Insurability Form Page 2
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1
2EVIDENCE OF INSURABILITY
Please list all life insurance and/or annuity contacts now in-force or pending on your life
1A.
Do you intend to replace or change this coverage
Existing
Name of Company
Life
AD&D
Year Issued
if you and your dependents are approved for the
Coverage
(if replacement include Policy No.)
Amount
Amount
or Pending
insurance applied for on this application?
YES
NO
YES
NO
1B.To be Completed for ALL Proposed Insured(s) if Required by the Group Insurance Contract
Have you used any form of tobacco products (cigarettes, pipe, cigars, chewing tobacco, nicotine gum or patches) within the past
12 months? **
Employee
YES
NO
Spouse
YES
NO
** I understand and agree that if I have not answered these questions correctly 1) the coverage may be rescinded during the first two years
from the certificate effective date, and 2) after that time, the sum payable and every other benefit will be adjusted to the amount which the
premiums would have purchased if the questions had been answered correctly.
2. Have ANY of the proposed insureds ever had or been told by a member of the medical profession that they had:
A. 1) asthma or emphysema; 2) high blood pressure, stroke, heart or circulatory disease or disorder; 3) intestinal disease or disorder
or ulcer; 4) diabetes; 5) leukemia, cancer, tumor or malignancy; 6) epilepsy, mental or nervous disease or disorder; 7) kidney or
genito-urinary disease or disorder; or 8) disorder of the back, muscles, bones or joints?
YES
NO
B. Have any of the proposed insureds been treated for or been diagnosed by a member of the medical profession as having an
immune deficiency disorder or AIDS (Acquired Immune Deficiency Syndrome)?
YES
NO
C. In the past 5 years, have any of the proposed insureds; 1) been hospitalized or had hospitalization recommended; 2) had a
physical examination or medical test with other than normal results?
YES
NO
D. Do you or your spouse: 1) fly, or intend to fly, as pilot or crew member; 2) race or test any form of vehicle; 3) scuba dive;
4) hang glide or sky dive?
YES
NO
E. Has any proposed insured used on a regular basis or are they currently using or ever received treatment or consultation for the
use of heroin, morphine, other narcotics, marijuana, barbiturates, amphetamines or hallucinogenic drugs or alcoholism?
YES
NO
3. Details for questions 2 - A, B, C, D, E answered “YES”. Include question number.
Name
Disease or Injury
Date (s)
Details/Treatment
Names & Address of Attending Phy’s & Hospitals
REPRESENTATIONS AND NOTICE TO APPLICANTS
I/we represent that the statements and answers in this Evidence of Insurability form are complete and true to the best of my/our knowledge
and belief. I/we agree that this form shall form the basis for and become a part of the consideration for the insurance applied for.
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 may have violated state law.
Signature of Applicant
Date
Signed & Dated at
(Employee/Member)
(City, State)
Signature of Applicant
(Other than Employee/Member)
Date
Signed & Dated at
(City, State)
(Employee/Member if the proposed insured is under 15)
Thank you for considering Boston Mutual Life Insurance Company as your insurance carrier.
Your application will receive our immediate and full consideration.
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