Statement Of Health Form (Page 3 of 3) in pdf

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.

AUTHORIZATION

1. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related

facility, insurance company, the Medical Information Bureau, Inc., or other organization, institution or person that has

any records or knowledge of me or my health, to give to the Company or its reinsurers any such information. Such

information will pertain to my employment, or other insurance carrier or medical care, advice, treatment or supplies for

any physical or mental condition. This includes that information obtained in connection with the preparation or

procurement of an investigative consumer report as defined under the Fair Credit Reporting Act(s). To facilitate the rapid

submission of such information, I authorize all said sources, except the Medical Information Bureau, Inc., to give such

records or knowledge to any agency employed by the Company to collect and transmit such information.

2.I understand that this information will be used by the Company solely to determine eligibility for insurance.

3.I understand that I may revoke this authorization at any time. I agree that such revocation will not affect any action which

the Company has taken in reliance upon this authorization. I understand this authorization will not be valid after 30

months, if not revoked earlier.

4.I know that I should retain a copy of this authorization for my records.

5.I agree that a photocopy of this authorization is as valid as the original.

6.To the best of my knowledge and belief, all statements made above are true and complete.

7. I understand that my application for group insurance will be accepted or declined on the basis of these statements.

Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full (a)

during the lifetime of all proposed insureds; and (b) while there is no change in the insurability or health of such person

from that stated in the application.

8.I authorize deductions from earnings for the costs of this insurance.

9.I designate the beneficiary named on this form to receive the proceeds, if any, payable upon my death.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,

information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

➧

(

DATE SIGNED)

(SIGNATURE OF EMPLOYEE/MEMBER)

➧

(DATE SIGNED)

(SIGNATURE OF SPOUSE, IF APPLYING FOR INSURANCE)

➧

Witness to above Signature(s):

BENEFICIARY DESIGNATION (Complete only if applying for Life/AD&D benefits)

Unless you otherwise request below, the employee/member named in 2 above will be the beneficiary of any spouse and/or

children’s insurance applied for, and the spouse named in 4 above will be the beneficiary of any employee/member insurance

applied for. For an employee/member, if you have no spouse or children and no one is named below, proceeds will be payable

to the estate of the insured:

Ex: Mary A. Jones, Wife

First Name

Initial

Last Name

Relationship

Not Mrs. John Jones

G-APP-40010

06673571-1005-HPS-6 R02/09

Statement Of Health Form Page 3

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