Fillable Evidence Of Insurability Form (Page 3 of 4) in pdf

Employee Name

SSN (Last 4 digits only.)

F. AUTHORIZATION AND ACKNOWLEDGMENT

(Please read and sign below)

For underwriting and claim purposes, I give my permission to any blood bank, blood center, plasma center, health care provider, any physician or other

medical practitioner, hospital, clinic, insurance or reinsuring company, MIB, Inc. (MIB), any consumer reporting agency, or any other organization to give

ReliaStar Life Insurance Company (ReliaStar Life) or its authorized representative (including any consumer reporting agency) acting on its behalf ALL

INFORMATION on my behalf (except as limited below). This includes but may not be limited to: (a) findings on medical care, psychiatric or psychological

care or examination, or surgery, as they apply to me; and (b) any non-medical information as it applies to me. I give my permission to ReliaStar Life to obtain

consumer or investigative consumer reports about me.

I give my permission to ReliaStar Life and other insurance companies affiliated with ReliaStar Life to obtain any and all medical record information for

the purposes described in this form. I know that my medical records, including any alcohol or drug abuse information, may be protected by Federal

Regulations–42 CFR Part 2. I may revoke this permission as it applies to any information protected by 42 CFR Part 2 at any time, but not to the extent

action has been taken in reliance on it. I specifically consent to the re-disclosure of medical record information as set forth in this form. In connection with

any application for life insurance, or other insurance transaction that I may have with ReliaStar Life or any of its affiliated companies, I understand that I may

request that this information not be communicated to companies affiliated with ReliaStar Life.

I authorize ReliaStar Life, or its reinsurers, to disclose personal health information about me to MIB, Inc. in the form of a brief coded report for participation

in MIB’s fraud prevention and detection programs.

I understand that my further written consent will be required before any information described above is given, sold, transferred, or, in any way, relayed to

another party not before specified. My further consent must be provided on a form that states the new use of the information or why another party needs it.

I know that I have a right to receive a copy of this form. I certify that I have, will print, or will otherwise have access to a copy of all pages of this Evidence

Form to keep for my records. A photocopy of this form will be as valid as the original. This form will be valid for 24 months from the latest date shown below.

I acknowledge that I have been given ReliaStar Life’s: Consumer Privacy Notice and Insurance Information Practices Notice.

IMPORTANT! Please carefully read the next section. Then sign and date below.

I declare that all of the statements and answers, as they pertain to me and to my child(ren), if applicable, on all pages of this Evidence Form are complete

and true to the best of my knowledge and belief.

I realize that any misrepresentation or omission regarding the presence of any pre-existing impairments and/or diseases may result in the

requested coverage or benefits provided by such coverage being contested. I understand that any claim incurred prior to the approval of this

Evidence Form by ReliaStar Life Insurance Company’s Home Office will not be valid.



Employee Signature

Date



Spouse Signature

Date

Return completed EOI to your payroll/HR Office for forwarding to NDPERS.

0000000000