Statement Of Health Form printable pdf download

Statement Of Health Form

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Statement of Insurability for Group Programs

American General Life Insurance Company of Delaware*

Wilmington, Delaware

Administrative Office: PO Box 30083, Tampa, FL 33630-3083

*This company does not solicit business in New York.

These Notices must be detached and retained by the applicant

MIB DISCLOSURE NOTICE

Information regarding your insurability will be treated as confidential. The Company or its reinsurers may, however, make

a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership

organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to

another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a

company, MIB, upon request, will supply such company with the information about you in its file.

Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at

866-692-6901 (TTY 866 346-3642). If you question the accuracy of the information in MIB's file, you may contact MIB and

seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB's

information office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734.

The Company, or its reinsurers, may also release information from its file to other insurance companies to whom you

may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers

about MIB may be obtained on its website at

NOTICE AS REQUIRED UNDER THE FAIR CREDIT REPORTING ACT(S)

This is to inform you that as part of our procedure for processing your insurance application, an investigative consumer

report may be requested for the preparation of a report whereby information is obtained through personal interviews

with your neighbors, friends, or others with whom you are acquainted or who may have knowledge of any such items of

information. This inquiry includes information as to your character, general reputation, personal characteristics, and

mode of living. You have the right to make a written request to be informed as to whether or not such consumer report

was requested, and if such report was requested, the name and address of the consumer reporting agency to whom the

request was made. You may receive a copy of this report by contacting such agency.

G-APP-40010

06673571-1005-HPS-6 R02/09

Statement Of Health Form