Insurance Exam Form

INSURANCE EXAM FORM

Applicant / Insured Information

Applicant Name:

Date of Birth: Gender:

Policy and Insurer Information

Insurer / Agency:

Policy Number: Policy Type: Life Health Disability Other

Requested Coverage Amount: Deductible: Premium Frequency:

Proposed Policy Period: From to

Exam Details

Date of Exam: Exam Location:

Examiner Name:

Vital Signs & Measurements

Height: Weight: Blood Pressure:

Pulse: Respirations: Temperature:

Medical History Summary (To be completed by Applicant)

Physical Examination Findings (Examiner)

Heart: Normal Abnormal — Describe:

Lungs: Normal Abnormal — Describe:

Neurologic / Extremities: Normal Abnormal — Describe:

Laboratory / Diagnostic Results

Exclusions, Limitations & Special Notes

Beneficiary Designation (If applicable)

Relationship: Percentage:

Relationship: Percentage:

Authorization, Certification, and Release

I, the Applicant, authorize the above-named insurer, its agents, and its representatives to obtain and review medical records, laboratory results, and other health information relevant to this examination and any insurance application. I authorize any physician, medical practitioner, hospital, clinic, laboratory, or insurer to release such information to the insurer. This authorization is valid for a period of twelve months from the date of my signature below unless otherwise revoked in writing.

I certify that the answers and statements in this Insurance Exam Form are complete and true to the best of my knowledge and belief. I understand that any materially false statement or omission may be relied upon by the insurer in determining eligibility for coverage and may result in denial of benefits or rescission of coverage as permitted by law.

Examiner Attestation (For Record Only)

I attest that the foregoing examination was conducted in accordance with accepted clinical practice and that entries above reflect the observations and test results obtained at the time of this examination.

Examiner Printed Name: License / ID #:

Additional Examiner Notes

Data Privacy and Use Notice

The insurer will maintain personal and health information obtained through this examination as confidential in accordance with applicable laws and institutional policies. Information may be used to evaluate eligibility for insurance, to adjudicate claims, and for underwriting purposes. The insurer may disclose information to reinsurers, claims administrators, and other parties with a need to know in connection with administration of the policy.

Applicant Certification

By signing below, I acknowledge receipt of a copy of this Insurance Exam Form, I consent to the examination, and I authorize the release and use of information as described above. I understand that this form, together with any statements by me in connection with my insurance application, will be relied upon by the insurer.

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