The process of ensuring that individuals are suitably covered by insurance, especially in scenarios requiring detailed health evaluations, can seem daunting. Yet, the form 1143 01, reserved for such instances, streamlines this necessity into a manageable task. Designed by Unum Life Insurance Company of America, a stalwart in the insurance domain recognized for its commitment to providing seamless insurance solutions, this form stands as a fundamental step for applicants needing an individual underwriting to qualify for insurance coverage. The form meticulously guides applicants through the process, urging them to furnish complete and accurate responses concerning personal information, health history, and the specific coverage they seek, thus facilitating a smoother underwriting process. Failure to provide comprehensive answers could stall this process, underscoring the form's emphasis on precision and completeness. Additionally, it encompasses sections dedicated to health inquiries that span a spectrum of conditions and lifestyle choices, reflective of the insurer's thorough approach in evaluating risks and coverage entitlements. Moreover, the form enlightens applicants on the subsequent procedures following submission, which may include medical evaluations at no extra cost, thereby assuring transparency and support throughout. However, it duly warns about the repercussions of providing false or misleading information, highlighting the legal and ethical expectations bestowed upon the applicant. This exhaustive formulation of the form not only aids Unum in safeguarding against potential fraud but also fortifies the trust between the insurer and the insured, ultimately ensuring that deserving applicants receive their rightful coverage.
| Question | Answer |
|---|---|
| Form Name | Form 1143 01 |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | HIV, unum eoi, NPI, TIA |
INSTRUCTIONS AND INFORMATION FOR
COMPLETING THE EVIDENCE OF
INSURABILITY FORM
Unum Life Insurance Company of America
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiar- ies. The insurance product is underwritten by Unum Life Insurance Company of America.
To expedite processing, this form has been designed to be scanned and optically read. Please print neatly and respond to all questions.
1.Fully complete this form when your plan requires you to be individually underwritten to qualify for insurance. Specify what coverage you are requesting. If you are unsure, check with your plan admin- istrator.
2.Make sure you have answered all the questions completely and accurately. Information pertaining to your Employer name, address and Group number, as well as your personal information must be provided. If there are unanswered questions, the underwriting process will not begin.
3.All employees and spouses applying for any coverage requiring underwriting must answer all health
questions through section 2. If you are applying for disability coverage, or your life amount requiring underwriting is greater than $150,000, you must also ill out section 3.
4.Please include your work and home phone number; we may need to request additional information by telephone.
5.Please sign and date where indicated and make a copy of this form for your records. Please send the completed form to your plan administrator or mail the form directly to:
Unum
P.O. Box
In order to evaluate your application we are relying on the information you have provided. In addition, we may need to request supplemental information from you or your physicians. Some coverage and amounts may require a brief medical exam, a blood test, urinalysis and/or EKG. These tests will be per- formed at your convenience and can be completed at your place of employment or home. We will notify you if any additional information is needed. Unum will pay for any additional information or tests needed to evaluate your application.
CAUTION: If your answers on the application are incorrect or untrue, Unum may deny beneits or rescind your insurance. Any person who, knowingly and with intent to defraud or deceive any insurance compa- ny, submits an insurance application containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law.
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EVIDENCE OF INSURABILITY |
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Unum Life Insurance Company of America |
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Application Type: Initial Request |
Late Applicant |
Annual Enrollment |
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Change in Status Increase |
Portability |
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List Your Current Height |
Weight |
List Your Spouse’s Current Height |
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Employee Social Security Number |
Gender |
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Employee First Name
Male Female
M.I. Last Name
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x x x x x x 0 0 0 1
Date of Birth - mm/dd/yyyy
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Spouse First Name (if applicable) M.I. Last Name |
Spouse Date of Birth - mm/dd/yyyy |
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Number & Street Address |
Employee Home Number |
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B O S T O N
M A 0 2 1 2 0
Employee
Total Life Amount
Applied For
$,, $
Amount Requiring Underwriting
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Total Life Amount
Applied For
$,,
Spouse
Amount Requiring
Underwriting
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Names of Dependent Children Applying for Coverage |
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Date of Birth - mm/dd/yyyy |
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Total Life Amount |
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(4/07) |
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1213205164664 |
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6477399364 |
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Please answer the following questions to the best of your knowledge and belief:
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Has any person applying for coverage been diagnosed as having Acquired Immune Deiciency |
Yes No |
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Syndrome (AIDS)? Applicant need not disclose Human Immunodeiciency Virus (HIV) test results. |
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Section 1 Dependent Children Health Questions |
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1.Within the past 5 years, have any dependent(s) been treated for diabetes, heart disorder, or cancer
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(other than basal or squamous cell carcinoma of the skin)? Do any dependent(s) have cerebral palsy, |
Yes |
No |
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cystic ibrosis or muscular dystrophy? If yes, please provide name(s) of children. |
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Section 2 Employee and Spouse Health Questions |
Employee |
Spouse |
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All employees and spouses applying for coverage must complete this section. |
Yes No |
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Yes No |
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1. |
Within the past 2 years, have you used any controlled substances with the exception of those |
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prescribed by a physician, received medical advice or sought treatment for drug or alcohol abuse, or |
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pled guilty, pled no contest to or been convicted of a felony, misdemeanor, or a charge of operating a |
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motor vehicle under the inluence of drugs and/or alcohol? |
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2. |
Within the past 2 years, have you been prescribed three or more medications to be taken |
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concurrently for high blood pressure? |
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3. |
Within the past 5 years, have you received medical advice or sought treatment for psychosis, |
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internal cancer including melanoma, leukemia or Hodgkin’s disease, ALS, muscular dystrophy, |
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angina, or had heart surgery, heart attack or transient ischemic attack (TIA)? |
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4. |
Within the past 10 years, have you received medical advice or sought treatment for stroke, |
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congestive heart failure, chronic lung disease including emphysema, diabetes treated with insulin or |
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oral medications, hepatitis (other than type A), cirrhosis of the liver, chronic renal disease including |
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hypertension or failure, systemic lupus or any connective tissue disease? |
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5. |
Are you confined to a wheelchair for reasons other than paraplegia? |
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Section 3 If your amount requiring underwriting is greater than $150,000 or you are applying for |
Employee |
Spouse |
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disability coverage, you must complete section 3. Otherwise, please sign and return application. |
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If you answer yes, please provide details requested in the box on the following page. |
Yes No |
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Yes No |
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Within the past 2 years, have you lown as a student or private pilot, engaged in auto or boat racing, |
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scuba diving, hang gliding, ballooning, lying ultralights, parachuting, mountain climbing or any similar |
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sport or avocation? |
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Have you ever used barbiturates, amphetamines, cocaine, hallucinogenic drugs or any narcotics |
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except as prescribed by a physician or been advised to reduce your consumption of alcohol or been |
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treated, arrested in connection with alcohol, or been told to have counseling for the use of alcohol |
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or drugs? If yes, provide the frequency of use and date last used, list condition(s), medication(s), |
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date(s) of treatment, treatment received and recovery, physician’s/hospital name, address and phone |
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number, date of occurrence and driver’s license number and issuing state of any arrest. |
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3. |
Have you ever pled guilty to, pled no contest to or been convicted of a felony or misdemeanor? If |
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yes, list person’s name, reason for arrest(s) and/or are you currently on probation. |
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4. |
Within the past 2 years, have you pled guilty to, pled no contest to, or been convicted of 3 or more |
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speeding or other moving violations? If yes, list person’s name, type of violation(s) and date(s), |
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driver’s license number and state of issue. |
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5. |
Within the past 10 years, have you received medical advice or sought treatment for epilepsy, |
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nervous, emotional or mental disorder, paralysis, skin, bone, muscle, back, knee, neck or joint |
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disorder, muscular or neurological disorders, Fibromyalgia, or Chronic Fatigue Syndrome. If yes, list |
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condition(s), medication(s), date(s) of treatment, treatment received and recovery, physician’s/hospital |
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name, address and phone number. |
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6. |
Within the past 7 years, have you received medical advice or sought treatment for diabetes, asthma, |
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lung or respiratory disorder, thyroid or other endocrine disease, heart or circulatory disorder, stroke |
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(including TIA), chest pain, high blood pressure, cancer, |
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disease? If yes, list condition(s), medication(s), date(s) of treatment, treatment received and recovery, |
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physician’s/hospital name, address and phone number. |
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7. |
Within the past 7 years, have you consistently taken any over the counter medications, natural |
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supplements other than vitamins, or received any therapeutic treatments? If yes, list all over the |
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counter medications including any natural supplements, dosage, condition and date of onset. Please |
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also list therapies and associated conditions and dates treatment received. |
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8. |
Within the past 7 years, have any medications been prescribed or have you consulted a medical |
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professional for anything other than the conditions above, or are you currently experiencing any |
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symptoms for which you haven’t consulted a medical professional? If yes, provide details including |
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symptoms, dates of occurrence, medications, treatment and medical professional’s name, address |
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and phone number. |
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9. |
Do you have any condition that prevents or limits activities or are you now pregnant? If yes, provide |
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details including symptoms and describe the limitation(s). If pregnant, please provide expected |
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delivery date. |
7753399362 |
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Details for any “yes” answers
Question
Number
Name
Detailed Description
Date
Duration
Treatment Received
and Recovery
Names and Addresses of Physicians and Hospitals
Please attach additional sheet if you need additional space
Authorization
I authorize any person or organization to give Unum subsidiaries or their duly authorized representatives (Unum) any of
the following:
• information about any injury or illness I have or I have had, including Acquired Immune Deiciency Syndrome (AIDS), mental illness or drug or alcohol abuse. This authorization excludes disclosure of Human Immunodeiciency Virus (HIV) test results. Such test results shall not be disclosed or published. I understand that nothing in this caveat will prohibit this authorization from including the fact that an applicant has Acquired Immune Deiciency Syndrome (AIDS).
• information about my medical history including any consultations, prescriptions, treatments or beneits.
• copies of all records that may be requested concerning me or my family members, and
•
The term person or organization, which is used above, means a physician or medical practitioner, a hospital, clinic or other medical treatment facility, any insurance or reinsurance company, insurance support or reporting agency, pharmacy, government agency, or employer.
I understand that the information obtained by use of this authorization will be used by Unum to determine eligibility for insurance and eligibility for beneits. Unum will not release any of the obtained information to any other person or organization except reinsuring companies or other persons or organizations performing services in connection with my
application or claim.
I understand that this authorization shall be valid for two years from the date shown on the application and that a photographic copy of this authorization shall be as valid as the original. I understand that I have the right to revoke this
authorization at any time except to the extent it has been relied on prior to written notice of revocation. I also understand that, if I revoke this authorization, such revocation may be a basis for denying insurance beneits. This authorization may be revoked by sending written notice to: Unum, Attn: Group Medical Underwriting, P.O. Box
04104.
The statements I have made on this application are true to the best of my knowledge and belief, and I understand that they form the basis of any coverage under the group policy for which Evidence of Insurability is required. I have read and understand the Authorization, and I and my authorized representative have a right to receive a copy. I understand that
failure to sign this Authorization may impair Unum’s ability to process my application or evaluate a claim, and that this may be a basis for denying my application or claim for beneits.
I have received a copy of Unum’s privacy notice (“Unum’s Commitment to Privacy”). I understand Unum will not collect or share information about me with the Medical Information Bureau (MIB) or order an investigative consumer report from a consumer reporting agency to determine my eligibility for the coverage for which I am applying.
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Employee Signature |
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Spouse Signature |
Date |
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_____________ |
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Child Signature (if 18 or older) |
Date |
1213205164664 |
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Unum’s Commitment to Privacy
Unum understands your privacy is important. We value our relationship with you and are committed to protecting the conidentiality of nonpublic personal information (NPI). This notice explains why we collect NPI, what we do with NPI and how we protect your privacy.
Collecting Information
We collect NPI about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may re- ceive NPI from your applications and forms, medical providers, other insurers, employers, insurance support organizations, and service providers.
Sharing Information
We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insur- ance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policyholders for reporting and auditing purposes. We may share NPI with parties to a proposed or inal sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legally necessary, we ask your permission before sharing NPI about you. Our practices apply to our former, current and future customers.
Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market
The law allows us to share NPI as described above (except health information) with afiliates to mar- ket inancial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other inancial institutions to jointly market inancial products and services. When required by law, we ask your permission before we share NPI for marketing purposes.
When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.
Unum companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include inancial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you.
Safeguarding Information
We have physical, electronic and procedural safeguards that protect the conidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you.
Access to Information
You may request access to certain NPI we collect to provide you with insurance products and ser- vices. You must make your request in writing and send it to the address below. The letter should in- clude your full name, address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs.
This section applies to NPI we collect to provide you with coverage. It does not apply to NPI we col- lect in anticipation of a claim or civil or criminal proceeding.
Correction of Information
If you believe NPI we have about you is incorrect, please write to us. Your letter should include your full name, address, telephone number and policy number if we have issued a policy. Your letter should also explain why you believe the NPI is inaccurate. If we agree with you, we will correct the NPI and notify you of the correction. We will also notify any person who may have received the incor- rect NPI from us in the past two years if you ask us to contact that person.
If we disagree with you, we will tell you we are not going to make the correction. We will give you the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reason(s) why you disagree with our decision not to correct the NPI in our iles. We will ile your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by you if we may have disclosed the disputed NPI to that person in the past two years.
Coverage Decisions
If we decide not to issue coverage to you, we will provide you with the speciic reason(s) for our deci- sion. We will also tell you how to access and correct certain NPI.
Contacting Us
For additional information about Unum’s commitment to privacy, please visit www.Unum.com/privacy or www.coloniallife.com or write to: Privacy Oficer, Unum, 2211 Congress Street, C467, Portland, Maine 04122. We reserve the right to modify this notice. We will provide you with a new notice if we make material changes to our privacy practices.
Unum is providing this notice to you on behalf of the following insuring companies: Unum Life Insur- ance Company of America, First Unum Life Insurance Company, Provident Life and Accident Insur- ance Company, Provident Life and Casualty Insurance Company, Colonial Life & Accident Insurance Company, The Paul Revere Life Insurance Company and The Paul Revere Variable Annuity Insurance Company.
© 2007 Unum. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. The insurance product is underwritten by Unum Life Insurance Company of America.