Statement Of Health Form Page 2
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1
2
3Statement 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.
Please print or type all information requested.
Group Policy Number ________________________ Billing Location ________________________
Salary __________________ Supplemental Life amount________________________
All applications missing information will be returned.
(if applicable)
Job Title ____________________________ Hire Date ____________________
1. Name of Employer __________________________________________________________________________________________________________
2. Employee's/Member’s full name ______________________________________________________________________________________________
FIRST
MIDDLE
LAST
3. Home Address ______________________________________________________________________________________________________________
NUMBER
STREET
CITY
STATE
ZIP
HOME TELEPHONE NUMBER
4. Complete the following for employee/member and dependents requesting coverage (Only complete for children if late entrants).
Date of Birth
Name
Age MM/DD/YY Sex
Place of Birth
Height
Weight
Social Security #
EE
ft.
in.
lbs.
SP
ft.
in.
lbs.
CH
ft.
in.
lbs.
CH
ft.
in.
lbs.
EMPLOYEE/
SPOUSE
CHILD
MEMBER
5.
Have you ever been diagnosed with or treated for any disease or disorder of
Yes
No
Yes
No
Yes
No
the heart, kidneys, liver or lungs, cancer or other tumor, AIDS (Acquired Immune
Deficiency Syndrome), AIDS related complex or other immune disorder,
diabetes or high blood pressure, mental or nervous disorder, alcohol or
drug dependency, arthritis or other musculoskeletal disease or disorder?
6a. Have you, during the past 5 years, consulted any physician or other practitioner
Yes
No
Yes
No
Yes
No
or been confined or treated in any hospital or similar institution?
6b. Are you presently taking any medication?
Yes
No
Yes
No
Yes
No
6c. Have you, in the last 12 months, missed more than 5 consecutive days
Yes
No
of work due to illness or injury?
If "yes" to any part of questions 5 and 6, give details below. Use a separate sheet of paper if more space is
needed for answers:
Question
Does Question Apply to
Date
Degree of
Name, Address & Phone # of Physicians
No.
Employee, Spouse or Child
Condition
Occurred
Duration
Recovery
Hospitals/Clinics Consulted
SIGNATURE IS REQUIRED ON THE FOLLOWING PAGE
G-APP-40010
06673571-1005-HPS-6 R02/09
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