Fillable Evidence Of Insurability Form (Page 2 of 4) in pdf

Employee Name

SSN (Last 4 digits only.)

E. EMPLOYEE AND SPOUSE HEALTH QUESTIONS (

Must be answered for coverage that is not Guaranteed Issue.)

Employee (EE)

Spouse (SP)

Yes

1. Have you ever been diagnosed or treated by a member of the medical profession as having AIDS, ARC, or the



HIV infection?

2. Have you ever had, or been treated for, any of the following: insulin dependent diabetes, heart attack, coronary bypass/



angioplasty, heart valve repair/replacement, stroke, metastatic cancer, emphysema or been an organ transplant recipient?

Complete for EE and SP. --- >

3. Employee: Height

ft.

in. Weight

lbs. Spouse: Height

ft.

in. Weight

lbs.

4. In the past 10 years have you consulted with, been diagnosed or treated by a health practitioner, or taken medication

for any of the following:

a. Disease or disorder of the heart, blood vessels (excluding controlled high blood pressure), lung (excluding asthma),



liver (excluding hepatitis A), pancreas, or intestine?

b. Non-insulin dependent diabetes, impaired glucose tolerance, or pre-diabetes?



c. Cancer or tumor, rheumatoid arthritis, connective tissue, neurological (excluding headaches), autoimmune or blood disorder?



d. Depression, psychosis, suicide attempt, drug or alcohol abuse or addiction?



e. Polycystic kidney disease or kidney failure?



5. Have you ever been diagnosed, treated or given medical advice by a physician or other health practitioner for:

a. Chest pain, heart trouble or circulatory disorder?



b. Anemia or leukemia?



c. Sleep apnea, asthma or other respiratory disorder?



d. Colitis, Crohn’s disease, ulcerative colitis or any other intestinal disorder or disease?



e. Stomach disorder?



f. Brain or seizure disorder?



g. Mental or nervous disorder?



h. Arthritis, paralysis or any muscle weakness?



i. Abnormal urine specimen or urinary tract disorder?



j. Prostate or other reproductive organ disorder?



6. Are you pregnant? Due Date

Pre-pregnancy weight

lbs



7. Do you currently have any disorder, condition, disease, and/or are you currently taking medication prescribed or



provided by a physician or other health practitioner for any disorder, condition, disease not shown above?

8. Have you ever received medical treatment or counseling for the use of alcohol or prescribed or non-prescribed drugs,



or been advised by a health practitioner to discontinue the use of such substances?

9. In the past 2 years have you experienced any symptom(s) for which you have not yet consulted a health practitioner,



or are any medical, surgical or diagnostic procedures recommended or contemplated?

If applying for disability income coverage, please complete this additional question:

- N/A -

10. In the past 5 years have you experienced symptoms of or been treated for arthritis, fibromyalgia, back or neck disorder,



spinal disorder, joint or bone disorder, muscle disorder, carpal tunnel syndrome or chronic pain?

For every “Yes” answer, to any question in the previous section, give details below. Please attach a separate sheet if additional space is needed.

Date

Health Practitioner Name, Full

Condition

Description of

Address (Street, City, State, ZIP),

Description of Condition

Began

Treatment Received

Phone

 EE

 Yes

 SP

 No

 EE

 Yes

 SP

 No

 EE

 Yes

 SP

 No

 EE

 Yes

 SP

 No

 EE

 Yes

 SP

 No

0000000000

RL-EOI-2011-ND

Page 2 of 3 - Incomplete without all pages.

Order #162278 ND 09/01/2014

Evidence Of Insurability Form Page 2

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