Sample Evidence Of Insurability Form Page 2
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2ONLY COMPLETE FOR THOSE EMPLOYEES WHERE EOI IS REQUIRED
AND ONLY FOR THOSE COVERAGES WHERE EOI IS REQUIRED.
Part A
Employer/Association Information
Complete this page as applicable to the plan(s) requiring evidence of insurability, then give this package to the
employee/member.
Employee/Member First Name
MI
Last Name
J a n e
P
D o e
Date of Birth
Social Security Number
Sex
x
1 1
1 0
5 4
1 2 3
4 5
6 7 8 9
Male
Female
Date employee
Street
Apt.
became eligible for
benefits—for new
3 6
P a l m
D r i v e
employees this is
the date of hire if
City
State
ZIP code
no waiting period
applies.
L i v i n g s t o n
N J
0 7 0 3 9
0 7
0 1
0 1
Date individual first became eligible for coverage(s)/amount(s) of insurance this form applies to:
48,000
Employee/Member Annual Earnings:
$______________________________
A late entrant
is an applicant
x
Is application being made for amounts above the Life non-medical maximum?
Yes
No
who applies for
Is application being made as a late entrant?
x
Yes
No
insurance or
an increase in
x
Is application being made for dependents?
Yes
No
insurance after
the initial eligibility
date, typically
31 days.
Life/AD&D
200,000
Total Non-Medical Maximum
$
(Guaranteed Issue Amount)
_________________________
Current Amount Inforce
+
Addt’l or Initial Amount Requested
=
Total Amount
150,000
250,000
400,000
Employee/Member
$
+
$
=
$
_________________________
____________________________________
________________
0
50,000
50,000
Spouse
$
+
$
=
$
The amount the
_________________________
____________________________________
________________
applicant already
EOI NOT REQUIRED
EOI NOT REQUIRED
Child
$
+
$
=
$
_________________________
____________________________________
________________
has inforce. This
would usually not
include Basic
Term life
Long Term Disability
(This should always reflect a monthly benefit amount)
coverage unless
(Examples assumes current amount is 50% base plan and the additional amount or initial amount requested is a 10% buy-up plan.)
the Non-Medical
Current Amount Inforce
+
Addt’l or Initial Amount Requested
=
Total Amount
Maximum amount
also includes the
2,000 per mo.
400
2,400
Employee/Member
$
+
$
/mo
=
$
_________________________
_______________________________
________________
Basic amount.
*($48K÷12X50%)
*($48K÷12X10%)
Survivor Benefits Life
+
=
Current Amount Inforce
Addt’l or Initial Amount Requested
Total Amount
Although benefit
0
800
800
applies to spouse
Spouse
$
/mo
+
$
/mo
=
$
____________________
_______________________________
________________
& child; it is the
0
100
100
employee who
Child
$
/mo
+
$
/mo
=
$
____________________
____________________________
________________
submits evidence
of insurability.
Weekly Disability Income/Accident & Sickness Benefit
(This should always reflect a weekly benefit amount)
750.00
$
Amount
_________________________
GL.2001.082
10/2002-2.5M
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