Evidence Of Insurability Form

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EVIDENCE OF INSURABILITY (ND)
ReliaStar Life Insurance Company, Minneapolis, MN
A member of the Voya family of companies
PO Box 20, Mail Stop 4-S, Minneapolis, MN 55440
Phone: 612.342.7262
Fax: 612.467.8721
Use this form to apply for insurance coverage in addition to coverage you may already have through this plan.
Group Number
Account Number
Employer Name
673897
1
NDPERS
Option 1
Option 2
Option 3
Option 4
Structure I
Structure II
Structure III
Structure IV
A. EMPLOYEE INFORMATION
Employee Name (First, MI, Last)
Gender:  Male  Female
SSN
Personal E-mail Address
Birth Date
Address
City
State
ZIP
Home Phone (
)
Cell Phone (
)
Hire Date
Salary $
Occupation
Primary Health Practitioner
Practitioner Phone (
)
Practitioner Address
City
State
ZIP
B. INSURANCE DETAILS
(Complete this table based only on the coverage you have through this plan.)
Are you completing this form due to a Family Status Change (Marriage, Divorce, Birth, Adoption, etc.)?
 Yes
 No
(A)
(B)
(C)
(A) – (B) – (C) = Amount
Coverage Type
Total Amount Desired
Current Amount
Guaranteed Issue Amount
To Be Underwritten
 Employee Supplemental Life
$
$
$
$
 Spouse Supplemental Life
$
$
$
$
 Dependent Spouse
$
$
$
$
Supplemental Life
 Dependent Children
$
$
$
$
Supplemental Life (per child)
C. SPOUSE INFORMATION
Spouse Name (First, MI, Last)
Gender:  Male  Female
SSN
Personal E-mail Address
Birth Date
Home Phone (
)
Cell Phone (
)
 Same Primary Health Practitioner as Employee (See information above.)
Primary Health Practitioner
Practitioner Phone (
)
Practitioner Address
City
State
ZIP
D. CHILD INFORMATION
(Availability of Child coverage is dependent on plan rules and may also be dependent on approved
employee coverage. If more than 3 children, list information on additional sheet.)
Name (First, MI, Last)
Birth Date
Gender
Relationship
 Male
 Female
 Male
 Female
 Male
 Female
Dependent Children Health Questions (Answer these questions only if applying for dependent child(ren) coverage.)
1. Within the past 5 years, have any dependent children been treated for or diagnosed with a mental or nervous disorder (excluding
ADHD), diabetes, heart disorder, cancer, asthma (requiring hospitalization within the last 2 years), or chemical abuse? . . . . . . . .  Yes  No
2. Do any dependent children have cerebral palsy, cystic fibrosis, muscular dystrophy, developmental disorder (including Autism and
Down’s Syndrome), or complications associated with premature birth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  No
For each “Yes” answer, provide name(s) of child(ren) and details.
0000000000
RL-EOI-2011-ND
Page 1 of 3 - Incomplete without all pages.
Order #162278 ND 09/01/2014

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