Short Form Health Statement

Transcript

1 GROUP INSURANCE The Prudential Insurance Company of America Employer: Branch No.: Group Contract No.(s): 0 0 (Submit a separate form for each person whose coverage requires Evidence of Insurability.) Short Form Health Statement Employee Last Name MI First Name P.O. Box / Apt. Number Number and Street ZIP Code State City _ Telephone Social Security Number Employee ID Number _ _ _ _ Email Address Name of Person for Whom Insurance is Being Requested Relationship to Employee: Spouse or Domestic Partner Self First Name MI Social Security Number Last Name _ _ Coverage that requires Evidence of Insurability: Life Spouse or Domestic Partner Life Employee Weight: Height: Date of Birth: (mm-dd-yyyy) Gender: _ _ Female Male lbs. in. ft. Please answer these questions by checking “Yes” or “No”. Note: In this section, “you” refers to the person for whom the insurance is being requested. Yes No have any disorder, condition, or disease that has been diagnosed or treated by a licensed medical professional or are Do you currently you currently taking prescription medication for any disorder, condition, or disease (other than: acid reflux; allergies; cold; cough; herniated disc; high cholesterol; nonrheumatoid arthritis; overactive or underactive thyroid; or pregnancy)? or other facility for any of the following? have you been diagnosed with, treated for, or been in a hospital In the last five years Yes No • Diabetes; Chest pain, heart disease or disorder, high blood pressure; • Mental or nervous disorder; • Cancer, tumors; • Respiratory disease or disorder of the lungs; • Alcoholism, drug addiction; • • Multiple sclerosis, epilepsy, seizure, stroke; Chronic pain, rheumatoid arthritis, lupus; or • Kidney, liver or pancreas disease or disorder; • Colitis, Crohn’s disease, gastric bypass. • have you been diagnosed or treated by a licensed member of the medical profession for AIDS or AIDS In the last five years, No Yes related complex? Prudential reserves the right to request additional health information on the basis of the responses given to the above questions. *LSFACA001* Page 1 of 3 Ed. 12/2015 L CA GL.2015.035 (21) *LSFACA001*

2 Branch No.: Group Contract No.(s): 0 0 Important Notice: For residents of all states except: Alabama, Arkansas, District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, North Carolina, Pen New Any person Jersey, nsylvania, Puerto Rico, Rhode Island, Utah, Vermont, Virginia New York, and Washington; WARNING: kno ther person, or nsurance company or o who knowingly and with intent to injure, defraud, or deceive any i wing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state payment of for prison. In addition, an insurer may law. Penalties may onfinement in include fines, civil damages and criminal penalties, including c deny insurance benefits if false for the purpose of applicant conceals, vided by the applicant or if the erially related to a claim was pro information mat misleading, information concerning any fact material thereto. efit or who knowingly presents t claim for payment of a loss or ben owingly presents a false or fraudu Any person who kn ALABAMA RESIDENTS— len false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. or ARKANSAS, DISTRICT OF COLUMBIA, LOUISIANA and RHODE ISLAND RESIDENT S— Any person who knowingly presents a false or fraudulent claim f p ayment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines prison. and confinement in — KENTUCKY RESIDENTS Any person who knowingly and with intent to defraud any insurance company or other person files an app lication for mation concerning any fact material thereto ly false information or conceals, for the insurance containing any material purpose of misleading, infor crime. commits a fraudulent insurance act, which is a —Any person w MAINE and WASHINGTON RESIDENTS te, or misleading information t false, incomple ho knowingly provides o an insurance company the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. for MARYLAND RESIDENTS — Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly a crime and may be subject to fines and confinement in prison. willfully presents false information in an application for insurance is guilty of or NEW misleading information on an application for an insurance policy is subject to Any person who includes any false or — JERSEY RESIDENTS criminal and civil penalties. NORTH CAROLINA RESIDENTS — Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, knowing that the matter material to the claim may be guilty of a Class H felony. statement contains false or misleading information concerning a fact or d any insurance c ompany or other pers on files an application UTAH RESIDENTS— knowingly and with intent to defrau PENNSYLVANIA and Any person who purpose of misleading, informati information or c im containing any materially false for insurance or statement of cla on c onceals for the oncerning any criminal and civil penalties. material fact thereto commits a fraudulent insurance act, which is a crime and subje cts such person to efrauding presents false inf who knowingly and with the intention of d Any person ormation in an insurance application, or PUERTO RICO RESIDENTS— r benefit, or presents presents, help s, or causes the presentation of a fraudulent clai m for the payment of a loss or any othe more than one claim for the a fine of not less than five thousand dollars ctioned for each violation by a felony and, upon conviction, shall be san ame damage or loss, shall incur s ( rs, or both penalties. Should a ggravatin g $5,000) and not more than ten thousa nd dollars ($10,000), or a fixed term of imprisonment for three (3) yea c s, if extenuating circumstances present, ircumstances [be] present, the penalty thus established may be incr eased to a maximum of five (5) year are two (2) years. it may be reduced to a minimum of Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement VERMONT RESIDENTS — be guilty of a in an application for insurance may criminal offense under state law. — VIRGINIA RESIDENTS Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or have violated state law. files a claim containing a false or deceptive statement may *LSFACA002* Ed. 12/2015 L CA Page 2 of 3 GL.2015.035 (21) *LSFACA002*

3 Group Contract No.(s): Branch No.: 0 0 Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application FLORIDA RESIDENTS— containing any false, incomplete, or misleading information is guilty of a felony of the third degree. I have read and understand the terms and requirements of the fraud warnings included as part of this form. I declare that, to the best of my knowledge and belief, the statements made in this application are complete and true. I agree that the coverage applied for is subject to the terms of the plan and shall become effective on the date or dates established by the plan, provided the evidence of good health is satisfactory. _ _ Print Your First Name Your Social Security Number Last Name _ _ Date Signed (mm-dd-yyyy) Your Signature (unless a minor) _ _ Date Signed (mm-dd-yyyy) Relationship If Person for whom insurance is being requested is a minor, Signature of Parent, Guardian, or Person Liable for Support Please keep a copy of this form for your records. is Group Life Insurance coverage issued by The Prudential Insurance Company of America, a New Jersey company, 751 Broad Street, Newark, NJ 07102. © 2015 Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. *LSFACA003* Page 3 of 3 GL.2015.035 (21) Ed. 12/2015 L CA 193904 *LSFACA003*

4 Group Life and Disability Income Medical Underwriting NOTICE Thank you for choosing The Prudential Insurance Company of America (Prudential) for your insurance needs. Before we can issue coverage we must review your application/enrollment form. To do this, we need to collect and evaluate personal information about you. This notice is being provided to inform you of certain information practices Prudential engages in, and your rights, with regard to your personal information. We would like you to know that: Personal information may be collected from persons other than yourself or other • individuals, if applicable, proposed for coverage; • This personal information as well as other personal or privileged information subsequently collected by us may in certain circumstances be disclosed to third parties without authorization; • You have a right of access and correction with respect to personal information we collect about you; and • Upon request from you, we will provide you with a more detailed notice of our information practices and your rights with respect to such information. Should you wish to receive this notice, please contact: The Prudential Insurance Company of America Group Medical Underwriting P.O. Box 8796 Philadelphia, PA 19176 Information regarding your insurability will be treated as confidential. We may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life, disability, or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. In addition, upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at 866-692-6901. If you question the accuracy of the information in MIB’s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400 Braintree, Massachusetts 02184-8734. Information for consumers about MIB may be obtained on its website at www.mib.com. Please keep this notice for your records.

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