Medical History Statement - Long Form - Indiana - New Hampshire, 16126 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member/Employee Information section. Enter the Group Name and Number, and check who is applying (Member/Employee, Spouse, or Child). Provide the Member/Employee's name, birth date, occupation, salary, and identification numbers.
3. In the Applicant Information section, input the applicant’s details including their name, email address, street address, sex, birth date, birthplace, and contact numbers.
4. Complete the Application Information section by checking the type of coverage requested (Short Term Disability, Long Term Disability, Life). Fill in current amounts in force and additional amounts requested for each type.
5. Provide Physician Information by entering the doctor’s name, clinic name, phone number, address, and date last consulted along with reasons for consultation.
6. Answer all Medical History Statement Questions by checking 'yes' or 'no' for each question. If you answer 'yes', provide detailed information as required.
7. Finally, read through the Acknowledgment and Authorization section carefully before signing and dating at the bottom of page 3. Ensure you keep a copy for your records.

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