GROUP INSURANCE
The Prudential Insurance Company of America
Mail the completed form to:
Employer/Association Name:
The Prudential Insurance Company of America
Group Medical Underwriting, P.O. Box 8796
Philadelphia, PA 19176
Group Contract No.(s):
Branch No.:
0 0
0 00 0 01
Or fax the completed form to:
877-605-6671
Short Form Health Statement Questionnaire (A separate form must be completed for each person requiring Evidence of Insurability)
Employee/Member Information
First Name
MI
Last Name
Number and Street
P.O. Box / Apt. Number
City
State
ZIP Code
_
Social Security Number
_
Employee/Member ID Number
Telephone
_
_
_
E-Mail Address
Applicant Information Relationship to Employee/Member:
First Name
MI
Self
Spouse
Last Name
Social Security Number
_
Applicant Coverage requiring Evidence of Insurability: Employee/Member
Gender:
Female
Male
Life Spouse
Life
Weight:
Height:
Date of Birth: (mm-dd-yyyy)
_
_
_
ft.
in.
lbs.
Please answer these questions by checking “Yes” or “No.”
Do you currently have any disorder, condition (including pregnancy), or disease which has been diagnosed or treated by
Yes
No
a licensed member of the medical profession or are you currently taking medication prescribed or provided by a medical
or other practitioner for any disorder, condition (including pregnancy), or disease other than a cold, cough, or allergies?
Yes
No
During the last five years, have you been in a hospital or other institution for observation, rest, diagnosis, or treatment?
Yes
No
During the last five years, have you had life, disability, or health insurance declined, postponed, changed, rated-up,
cancelled, or withdrawn by an insurer?
Yes
No
Within the last five years, have you been diagnosed or treated by a licensed member of the medical profession for any
of the following: heart; chest pain; high blood pressure; cancer or tumors; diabetes; lungs; kidneys; liver; alcoholism;
mental, or nervous disorder?
Yes
No
Within the last five years, have you been tested positive for exposure to the HIV infection or been diagnosed as
having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
Prudential reserves the right to request additional health information on the basis of the responses given to the above questions.
*LSFHSQFL001*
GL.2007.761–G (2A)
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Group Contract No.(s):
Branch No.:
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0 00 0 01
Important Notice: For residents of all states except: Alabama, District of Columbia, Florida, Kentucky, Maryland, New Jersey, New
York, Pennsylvania, Rhode Island, Utah, Vermont, Virginia and Washington; WARNING: Any person who knowingly and with intent to
injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits
incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim
for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished
under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant
conceals, for the purpose of misleading, information concerning any fact material thereto.
ALABAMA RESIDENTS—Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
DISTRICT OF COLUMBIA AND RHODE ISLAND RESIDENTS—Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
KENTUCKY RESIDENTS—Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance 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.
MARYLAND RESIDENTS—Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
NEW JERSEY RESIDENTS—Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NEW YORK RESIDENTS—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, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. This notice ONLY applies to
accident and disability income coverage.
PENNSYLVANIA and UTAH RESIDENTS—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 material fact thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
VERMONT RESIDENTS—Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a
false statement in an application for insurance may be guilty of a criminal offense under state law.
VIRGINIA RESIDENTS—Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other
person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or
information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may
be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement
in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto.
WASHINGTON RESIDENTS—Any person who knowingly provides false, incomplete, or misleading information to an insurance company
for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits.
*LSFHSQFL002*
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FLORIDA RESIDENTS—Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
I declare that, to the best of my knowledge and belief, the statements made in this application are complete and true. I agree that
the coverage applied for is subject to the terms of the plan and shall become effective on the date or dates established by the plan,
provided the evidence of good health is satisfactory.
_
Print Applicant First Name
Last Name
_
Date Signed: (mm-dd-yyyy)
_
Applicant’s Signature (unless a minor)
_
Applicant’s Social Security Number
If applicant is a minor, Signature of Parent, Guardian or
Person Liable for Support of Applicant
Relationship
Date Signed: (mm-dd-yyyy)
Please keep a copy of this form for your records.
Group Life coverage is issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ 07102.
© 2012 The Prudential Insurance Company of America.
Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many
jurisdictions worldwide.
*LSFHSQFL003*
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Group Life and Disability Income Medical Underwriting
NOTICE
Thank you for choosing The Prudential Insurance Company of America (Prudential)
for your insurance needs. Before we can issue coverage we must review your
application/enrollment form. To do this, we need to collect and evaluate personal
information about you. This notice is being provided to inform you of certain
information practices Prudential engages in, and your rights, with regard to your
personal information. We would like you to know that:
•
Personal information may be collected from persons other than yourself or other
individuals, if applicable, proposed for coverage;
•
This personal information as well as other personal or privileged information
subsequently collected by us may in certain circumstances be disclosed to third
parties without authorization;
•
You have a right of access and correction with respect to personal information
we collect about you; and
•
Upon request from you, we will provide you with a more detailed notice of our
information practices and your rights with respect to such information. Should
you wish to receive this notice, please contact:
The Prudential Insurance Company of America
Group Medical Underwriting
P.O. Box 8796
Philadelphia, PA 19176
Information regarding your insurability will be treated as confidential. We may, however,
make a brief report thereon to the MIB, Inc., formerly known as Medical Information
Bureau, a non-for-profit membership organization of life insurance companies, which
operates an information exchange on behalf of its members. If you apply to another MIB
member company for life, disability, or health insurance coverage, or a claim for benefits
is submitted to such a company, MIB, upon request, will supply such company with the
information about you in its file. In addition, upon receipt of a request from you, MIB will
arrange disclosure of any information in your file. Please contact MIB at 866-692-6901.
If you question the accuracy of the information in MIB’s file, you may contact MIB and
seek a correction in accordance with the procedures set forth in the Federal Fair Credit
Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite
400 Braintree, Massachusetts 02184-8734. Information for consumers about MIB may be
obtained on its website at www.mib.com.
Please keep this notice for your records.
