Sample Evidence Of Insurability Form printable pdf download

Sample Evidence Of Insurability Form

G R O U P I N S U R A N C E

The Prudential Insurance

Company of America

Evidence of Insurability

Instructions for Employer/Association

1. Complete the form below.

2. Also complete all sections of the form noted “PART A”

including product related information as applicable to the

plan(s) requiring medical evidence of insurability.

3. The entire package should then be given to your employee

or member for completion of Part B.

In the space below, insert mailing address to which the

notice of action should be sent.

XYZ

Submitting Location:

_____________________________________

Branch subsidiary location & name

Employer/Association Name & Address:

Please make sure that you provide the name

of your employer and not the branch subsidiary

name.

ABC Company

123 Elm Street

Newark, NJ

12345

001

Group Contract No.

_____________

Branch

No._______________

Please include your company’s 5 digit

contract number on all applications.

(if applicable)

Signed for Employer/Association by:

Please complete so we can call

you if we have questions.

Mary Smith

Name

HR Director

Title

xxx-xxx-xxxx

Telephone Number

2/1/01

Date

GL.2001.082 5.2001-5M

Sample Evidence Of Insurability Form

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