Healthcare Statement of Insurability

HEALTHCARE STATEMENT OF INSURABILITY

Purpose: This Statement of Insurability is provided by the applicant to permit underwriting and evaluation of eligibility for health insurance coverage. The applicant certifies that all answers are true, complete and correctly recorded to the best of their knowledge. The applicant authorizes any licensed physician, medical practitioner, hospital, clinic or other medically related facility to furnish to the insurer or its representatives any and all medical information and records relevant to this application.

Applicant / Patient Information

Date of Birth:   Gender:

Insurance / Coverage Requested

Relationship to Subscriber:

Coverage Requested Effective Date:

Medical History — Current and Past Health

Height:   Weight:

1. In the past 10 years, have you been diagnosed with or treated for cancer, tumor, leukemia or lymphoma? Yes No

2. Have you been diagnosed with or treated for heart disease, hypertension, stroke, diabetes, kidney disease, or liver disease? Yes No

3. Have you had any surgery, hospitalization, or been advised to have surgery within the past 5 years? Yes No

4. Have you ever been treated for or tested positive for HIV/AIDS, hepatitis B or C, or any other blood-borne infectious disease? Yes No

5. Have you been treated for mental health conditions, substance dependence, or received counseling for depression, anxiety, or substance abuse within the past 5 years? Yes No

6. Are you currently pregnant or planning pregnancy within the next 12 months? Yes No

7. Do you use tobacco, nicotine products, or vaping devices? If yes, indicate frequency. Yes No

Physician / Treatment Information

Authorization, Certification and Notices

Authorization: I authorize any physician, medical practitioner, hospital, clinic, pharmacy, employer, insurance company or other organization, institution or person that has records or knowledge of me or my health to disclose to the insurer or its authorized representatives any such information for underwriting, claims adjudication, fraud investigation or as otherwise permitted by law. This authorization includes disclosure of past medical history, diagnosis, treatments, consultations, prescriptions, alcohol and drug treatment records, and mental health records.

Expiration: This authorization is valid for 24 months from the date of signature unless a different expiration date is specified below.

Authorization Expiration Date:

Certification: I certify that the statements and answers in this Statement of Insurability are complete and true to the best of my knowledge. I understand that any material misstatement or omission may result in denial of coverage, rescission of coverage, or other adverse action to the extent permitted by law. I further certify that I have read and understand the provisions of this form and that no information requested has been withheld.

Acknowledgement of Privacy Practices: By signing below, I acknowledge that I have been provided with the insurer's privacy practices and that I consent to the use and disclosure of my protected health information as described above for underwriting and claims purposes.

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