Healthcare EOI Application

Healthcare EOI Application

Purpose: This Evidence of Insurability (EOI) Application is submitted to request underwriting review for new or increased coverage under a health, life, disability, or supplemental benefit plan. The applicant certifies that the information provided is complete and true to the best of their knowledge and authorizes the release of medical information as described below.

Applicant Information

Applicant Name:

Male Female Other

Insurance & Employer Information

Coverage Requested

Requested Coverage Type (check all that apply):
Health Life Disability Critical Illness Other:

Medical History

Height:    Weight:

Tobacco Use (any form) — check if YES:

Within the past 5 years, have you been hospitalized or had surgery? Check if YES:

Treating Providers

Authorization & Release

I authorize any physician, medical practitioner, hospital, clinic, medical facility, insurer, or other organization or person that has my medical records or knowledge to disclose such records and information to the plan administrator, insurer, and their reinsurers and representatives for the purpose of underwriting, claims adjudication, or fraud investigation. This authorization includes, but is not limited to, records relating to mental health, substance use disorder, communicable disease, and HIV/AIDS where applicable by law.

I acknowledge that a photocopy or electronic reproduction of this authorization is as valid as the original and that information obtained pursuant to this authorization may be subject to redisclosure and may no longer be protected by certain privacy laws.

Authorization Expiration Date:

I have received and acknowledge the privacy practices notice as provided by the plan/insurer — check to acknowledge:

Certification

I declare that the statements and answers on this application are true, complete, and correctly recorded. I understand that intentional misrepresentation or omission of material facts may result in denial of coverage, rescission of coverage, or other remedies allowed by law. I authorize the plan administrator and insurer to investigate any statement contained in this application, to obtain medical records, and to use the information for underwriting and coverage determination.

By signing below I consent to electronic or paper communication in connection with this application and any underwriting or claims matters unless otherwise specified in writing.

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