Form Usic-2020ee - Employee Enrollment Form For Group Disability Page 2
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4Health Questions (For Employees Applying for Amounts of Insurance over the Guaranteed Issue Limit, Enrolling Late, Increasing
Coverage, or Enrolling again after having Cancelled Coverage)
Last Name
First Name
Middle Initial
Social Security No.
Please answer the following questions.
If you answer “YES” to any questions, please provide details in REMARKS below.
Height _________________________
Weight _________
1.
Have you gained or lost 10 or more pounds during the past 12 months?
Yes
No
If “YES”, how much? _________________
2.
Have you within the past 5 years:
Yes
No
a.
Received or been advised to receive any medication, treatment, surgery, therapy, testing,
observation, or consultation by a physician, surgeon or other health care provider (including
psychologist, counselor, dentist, chiropractor, osteopath, etc.) in any clinic, hospital, sanitarium,
health resort or any other health related facility?
b.
Used any illegal drugs?
Yes
No
3.
In the past 5 years, have you had, been treated for or been advised to seek treatment for persistent
Yes
No
cough, fatigue or swollen glands, pneumonia, chest discomfort, muscle weakness, unexplained weight
loss of ten pounds or more, patches in mouth, skin lesions, prolonged night sweats, visual disturbance or
recurring diarrhea, fever or infection?
4.
Have you ever been diagnosed as having acquired immunodeficiency syndrome (AIDS)?
Yes
No
5.
Are you pregnant?
Yes
No
6.
Have you ever had, been medically diagnosed, treated or been advised to seek treatment for:
Yes
No
Arthritis; back, neck or joint disorder; asthma; emphysema or lung disorder; cancer or tumors; diabetes;
alcohol, cocaine or drug abuse; high blood pressure; stroke or heart disease or disorder; depression;
psychological counseling; mental, nervous or eating disorder; seizures; or immune system disorder?
“Disorder” is defined as a disease, illness, injury and/or condition differing in any way from the usual or
normal state and/or structure.
Name, address and telephone number of personal physician _____________________________________________
______________________________________________________________________________________________
REMARKS – If you answered “YES” to any health question above, please provide details below. Should you require
additional space, please use a separate sheet of paper and attach it to this form.
Question No.
First Name
Description of illness, injury, or
Duration
Residual
Name and address of
pregnancy, medication or treatment
(dates) &
effects/
attending physician or
No. of
results
hospital (include zip code)
episodes
If Answering Health Questions, the Employee signature is required on page 4 of this form.
USIC-2020EE
Page 2
STD/LTD 12/08
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