RESET FORM
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.
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RL-EOI-2011-ND
Page 1 of 3 - Incomplete without all pages.
Order #162278 ND 09/01/2014