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- Click ‘Get Form’ to open the Medical History Statement in the editor.
- Begin by filling out the Member/Employee Information section. Enter your name, group number, and select who is applying (Member/Employee, Spouse, or Child). Provide your birthdate and date hired.
- Next, complete the Applicant Information section. Fill in the applicant's name, address, email, sex, birthdate, and residency status. Ensure you include social security numbers and contact information.
- In the Application Information section, indicate the type of application (Initial, Increase in Coverage, Late Application) and specify the coverage amount requested.
- Proceed to answer all Medical History Statement questions. Check 'Yes' or 'No' for each question and provide details for any 'Yes' answers. Use a separate sheet if necessary.
- Finally, review the Acknowledgment and Authorization section carefully before signing and dating at the bottom of page 2.
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| 2016 | 4.8 Satisfied (235 Votes) |
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