Insurance EOI Form

INSURANCE EVIDENCE OF INSURABILITY (EOI) FORM

Applicant Information

Policy / Plan Information

Type of Coverage Requested: Life AD&D Disability Other

Health, Lifestyle and Risk Questions

Answer all questions fully. For each question answered "Yes", provide full details in the space provided, including dates, treating provider names, treatments, and current status. Failure to disclose material information may result in denial or rescission of coverage.

1. Are you currently actively at work and performing all normal duties of your occupation? Yes No

2. Have you ever used tobacco or nicotine products within the past 12 months? Yes No

3. In the past 5 years, have you been diagnosed, treated, or advised to seek treatment for any of the following: cancer, heart disorder, stroke, diabetes, kidney disease, liver disease, chronic respiratory disorder, or any neurological disorder? Yes No

4. In the past 12 months, have you been hospitalized or had surgery, or are you currently under medical investigation or awaiting test results? Yes No

5. Have you been declined, postponed, rated, or required to pay extra premium for life or health insurance in the past 24 months? Yes No

Medical Authorization & Consent

I authorize any physician, medical practitioner, hospital, clinic, pharmacy, or other medical or medically related facility, insurer, or consumer reporting agency to release to the insurer and its representatives any information requested for purposes of underwriting, claims administration, or policyholder services. This authorization includes medical records, diagnostic test results, and prescription history. I understand that information obtained will be used to determine eligibility and may be subject to applicable privacy protections.

I authorize the release of records for a period extending back to the applicant's full medical history where necessary. A photocopy or electronic reproduction of this authorization shall be as valid as the original. I understand that I may revoke this authorization by delivering written notice to the company; however, revocation will not affect actions taken prior to receipt of revocation.

Exclusions, Limitations and Important Notices

The insurer may deny, reduce or rescind coverage for material misrepresentations or omissions on this form. For life insurance, contestability provisions may permit the insurer to contest the policy for misstatements during the contestability period specified in the policy. Suicide, self-inflicted injury, and fraud are subject to applicable policy exclusions. Coverage will become effective only upon acceptance of risk by the insurer and payment of any required premium, unless otherwise stated in the policy.

By signing below, I certify that all statements and answers on this form are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that any material misstatement or omission may be grounds for rescission or denial of benefits.

Beneficiary Designation

Designate the primary beneficiary(ies) to receive proceeds payable under the policy if applicable.

Documentation Checklist

Please provide copies of the following documents as applicable:

Government-issued photo identification

Relevant medical records and discharge summaries

Recent laboratory and diagnostic test reports

Attending Physician Statement (if requested)

Declaration and Applicant Certification

I hereby declare that the information given on this Evidence of Insurability Form is complete and true to the best of my knowledge and that I have not withheld any information which might affect acceptance of the application. I understand that any material misstatement or omission may result in denial of coverage, claim denial or policy rescission to the extent permitted by law. I understand that issuance of coverage is subject to the insurer's underwriting review and approval.

I authorize any required medical or investigative reports to be obtained for purposes of this application and for claims adjudication. I acknowledge receipt of the information on this form and agree that a photocopy or electronic copy of this authorization shall be as valid as the original.

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