Insurance Statement of Good Health

INSURANCE STATEMENT OF GOOD HEALTH

Insurer and Policy Information

Insurer Name:   Policy Number:

Certificate/Group Number:   Agent or Broker:

Applicant / Insured Information

Date of Birth:   Sex:   Phone:

Policy Details

Policy Type:   Coverage Amount:

Deductible:   Premium Amount:

Policy Period From:   To:

Health Declaration

The applicant must answer each question below. For each question answered "Yes" provide full details in the space provided, including dates, treating physician(s), diagnosis, treatment, and current status.

1. Within the past 12 months, have you used tobacco, nicotine products, or stopped use within the past 12 months?    Yes    No

2. Have you ever been diagnosed with, treated for, or currently have: cancer, leukemia, lymphoma, tumor, stroke, heart disease, diabetes, chronic lung disease, kidney disease, or hypertension?    Yes    No

3. Within the past 5 years, have you had any surgery, hospitalization, or been advised to have tests, diagnostic procedures, or specialist consultation that have not been completed?    Yes    No

4. Are you currently taking any prescription medication, receiving medical treatment, or under the care of a physician or other health professional?    Yes    No

5. Do you participate in hazardous activities such as aviation (other than as a fare-paying passenger), scuba diving, motor sports, or professional athletics?    Yes    No

Height:   Weight:

Provider Phone:   Date of Last Visit:

Beneficiary Information

Primary Beneficiary Name:   Relationship:

Allocation Percentage:

Exclusions, Authorizations, and Notice

I acknowledge that any material misrepresentation or omission of fact in this Statement of Good Health may void coverage, be grounds for rescission, or be used to deny benefits in accordance with the terms of the policy. Coverage is subject to all policy provisions, and this statement is a part of the policy application or certificate file.

I authorize any physician, medical practitioner, hospital, clinic, pharmacy benefit manager, employer, or other organization to release to the insurer or its representatives medical and other information regarding treatments, conditions, or services related to the questions contained in this statement. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

I understand that the insurer may require an examination or additional information before approving any change in coverage or payment of benefits. I understand that falsification or omission of material information may subject me to penalties, including denial of claim or rescission of coverage.

Declaration and Certification

I, the undersigned, declare under penalty of perjury under the laws applicable to the policy that the statements and answers contained herein are complete and true to the best of my knowledge and belief. I understand that this statement will be relied upon by the insurer in determining insurability and the terms of coverage. I agree that this Statement of Good Health becomes part of the policy or certificate and will be binding on all parties with an interest under the policy.

Sign Now