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The Aetna Evidence of Insurability (EOI) form is a critical document for individuals seeking life and disability insurance coverage through Aetna Life Insurance Company. This form is essential for employers and employees alike, as it collects pertinent information that Aetna will evaluate in order to determine eligibility for coverage. The initial section requires employers to provide comprehensive details including the control number, account specifics, and employee information such as social security number and earnings. In addition, it captures the type and amount of coverage requested for both life and disability benefits. Employees are then tasked with accurately reporting their health conditions, along with relevant details for dependents if coverage is sought for them. The form emphasizes the importance of full disclosure, as incomplete information can lead to processing delays or denials of coverage. Each party must sign off on the form, and Aetna maintains the right to verify health information through various means, including additional medical documentation if required. Furthermore, the form outlines the privacy rights of the individual and the consequences of misrepresentation, underscoring the significance of honesty in this application process. Proper completion and submission of the Aetna EOI form serve as the first step toward obtaining necessary insurance protection.

Aetna Evidence Of Insurability Example

Evidence of Insurability Statement

Life and Disability Coverage

Aetna Life Insurance Company

 

Read This Instruction Page Carefully.

 

Aetna may contact you directly to request additional information upon receipt of this completed Statement.

Instructions

 

Plan Sponsor

Complete Section A in its entirety. Be sure that:

(Employer)

• All items are completed.

 

Please Print

• The Control Number, Suffix and Account numbers are provided (A1).

•The Employee/Member’s Social Security Number is provided (A2).

•Both the Employee/Member’s and your name and address are shown in the spaces provided (A3 and A4).

•The telephone number of your authorized representative (A5), Employee/Member’s date of hire (A7) and Employee/Member’s home and work telephone numbers (A8) are provided.

•Your Employee/Member’s and your E-mail addresses are provided (A6 and A10).

•Employee/Member’s Annual Earnings is completed (A9).

•You check the appropriate box(es) for individual(s) requesting Life coverage. Provide the current (existing and guarantee issue) amount of coverage, requested additional (new) amount of coverage that needs an Evidence of Insurability, resulting total amount of coverage for each individual for whom coverage is being requested (A11).

•You check the reason for requested life coverage (A11).

•You check the appropriate Disability box(es) and provide current and requested amounts or percentage of coverage (A11).

•Section A is signed by your Authorized Representative (A12).

 

Give the form to your Employee/Member for his/her confidential submission to Aetna.

 

Aetna will advise you of its coverage decision. Employee/Member will be notified directly if coverage is denied.

 

 

Employee/Member

Verify that your name, address and Social Security Number as shown in Section A are complete and accurate. We may need

 

to direct additional inquiries to your attention.

Read the Privacy

Complete Section B. Be sure that:

Notice and

• All items are completed.

Misrepresentation

 

section on

• Only the names of individuals requesting coverage at this time are listed (B1).

“Page 2 of 4” of

• Height and Weight must be provided or this form will be returned unprocessed for your completion (B1).

the Insurability

• The appropriate boxes regarding dependent child coverage are checked, if applicable (B2a, B2b, and B2c).

Statement before

 

completing.

• Complete dates and details are given for all conditions checked in B3g, (B4).

•You need to inform us of any changes in your health or in any of the information provided which takes place

Please Print

after you complete and sign this form and before you receive our coverage approval notice.

 

•The form is signed by you. If you are requesting spouse coverage, the spouse’s signature is also required. Read the Certification, Acknowledgment and Authorization prior to signing the form (bottom of Section B).

Submission and

Make a copy for your records. Mail the original to:

 

 

Approval

Aetna Life Insurance Company

 

Fax to (Applications within the US):

1-800-792-9710

 

 

 

Medical Underwriting Department

OR

Fax to (International Applications Only):

1-402-474-8426

 

PO Box 83641

 

 

 

 

Lincoln, NE 68501-3641

 

 

 

 

If you have any questions, call us toll-free at:

1-800-660-9913

 

If a final underwriting decision cannot be made within six months, Aetna reserves the right to request a new Evidence of Insurability Statement.

The requested coverage will not be in effect unless and until evidence of insurability is submitted as required and is approved by Aetna.

Please Note: If this form is not completed in its entirety and signed, it will delay processing.

 

EOI

PH Sign Req’d

GR-67853 (7-14)

Page 1 of 4

Privacy Notice

In evaluating your insurability, we (Aetna) will rely primarily on the health information you furnish to us in this Evidence of Insurability Statement. In addition, however, we may ask you to take a physical examination, or request additional medical information about you from any of the sources specified in the authorization on Page 4 of 4 of this form.

Disclosure of Information to Others

All of this information will be treated as confidential and will not be disclosed to others without your authorization, except to the extent necessary for the conduct of our business and not contrary to any law. For example, Aetna Life Insurance Company may also release information in its file to its reinsurer(s) and to other life insurance companies to whom you may apply for coverage, or to whom a claim for benefits may be submitted. In addition, information may be furnished to regulators of our business and to others as may be required by law, and to law enforcement authorities when necessary to prevent or prosecute fraud or other illegal activities.

Your Right of Access & Correction

In general, you have a right to learn the nature and substance of any information in our files about you. You also have a right of access to such files (except information which relates to a claim or a civil or criminal proceeding), and to request correction, amendment or deletion of recorded personal information in states which provide such rights and grant immunity to insurers providing such access. We may elect, however, to disclose details of any medical information you request to your (attending) physician. If you wish to exercise this right, or if you wish to have a more detailed explanation of our information practices, please contact:

Aetna Life Insurance Company, Medical Underwriting Department, PO Box 83641, Lincoln, NE 68501-3641

Under New Mexico law, a resident of New Mexico has the right to register as a "protected person" in connection with disclosure of confidential domestic abuse information. If you wish to exercise this right, write to the address shown above.

Misrepresentation

Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents 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. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment 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 and confinement in prison. Attention California Residents: For your protection, California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention Missouri Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, denial of insurance and civil damages, as determined by a court of law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a court of law. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Attention New York Residents, the following statement applies only to your AD&D and Disability coverage: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GR-67853 (7-14)

Page 2 of 4

Evidence of Insurability Statement

Make a copy for your records.

Mail the original to:

Life and Disability Coverage

Aetna Life Insurance Company

 

Aetna Life Insurance Company

Medical Underwriting Department

PO Box 83641

 

 

Lincoln, NE 68501-3641

 

Customer Service: 1-800-660-9913

 

 

 

Fax to (Applications within the US): 1-800-792-9710

 

 

 

Fax to (International Applications Only): 1-402-474-8426

A. Plan Sponsor (Employer): Complete this Section - Please print.

 

 

 

 

 

 

 

 

 

 

1.

Control Number

Suffix

 

 

Account

 

2.

 

Employee/Member Social Security Number

 

 

 

 

473705

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Plan Sponsor Name & Mailing Address

 

 

 

 

 

4.

Employee/Member Name & Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

ZIP Code

 

 

 

City

 

 

 

State

 

ZIP Code

5.

Plan Sponsor - Authorized Representative

 

7a. Employee/Member

 

8.

Employee/Member Telephone Numbers (Including Area Code)

 

Telephone Number

 

 

 

Date of Hire (MM/DD/YYYY)

 

 

 

a. Work

(

)

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Plan Sponsor E-mail Address

 

 

7b. Employee/Member

 

 

 

b. Home

 

(

)

 

 

 

 

 

 

 

 

 

 

 

Rehire Date (MM/DD/YYYY)

 

 

 

c. May we leave a message?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Employee/Member’s Annual Earnings

 

 

 

 

 

 

10.

 

Employee/Member Work E-mail Address

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Coverage(s) Applied for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Life*

Employee/Member Basic Life Spouse

Employee/Member Supplemental, Optional or Voluntary Life Child(ren)

 

Employee/Member

 

 

 

Supplemental,

 

 

Employee/Member

Optional or

 

 

Basic Life

Voluntary Life

Spouse Life

Child(ren) Life

a.Current (Existing including Guarantee Issue) Amount of Life

Insurance Coverage?

$

$

 

$

 

$

b. Additional (New) Amount of Life Insurance Coverage requested?

$

$

 

$

 

$

c. Resulting Total Life Insurance Amount if Approved (a + b)?

$

$

 

$

 

$

*Reason for Requested Coverage (indicate all that apply).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annual Enrollment

Late Applicant

Life Event/Status Change, Reason:

Date:

 

 

 

 

New Hire, Date:

 

 

 

 

Other (Please explain)

 

 

 

 

 

 

 

 

 

 

Disability Coverages (Employee/Member Only):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Short Term Disability:

Current Amount $

 

 

 

 

or

 

%

Requested Amount $

 

 

 

 

or

 

%

 

 

Long Term Disability:

Current Amount $

 

 

 

 

or

 

%

Requested Amount $

 

 

 

 

or

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Plan Sponsor: I certify the above information is correct.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plan Sponsor - Authorized Representative Signature

 

 

Plan Sponsor - Authorized Representative Name (Please print)

 

Date Signed (MM/DD/YYYY)

 

B.Employee/Member: Complete this Section - Please print. All questions must be answered. Incomplete forms cannot be processed.

1.Only the Names of Individual(s) Requesting Coverage at this Time Should be Listed

Name

Employee:

Spouse:

Child(ren):

Relationship Birthdate (MM/DD/YYYY) Birthplace (City/State) Gender Height (ft., in.) Weight (lbs.)

Self

2.Complete these questions if dependent children are listed above. Use Number 4 if additional space is needed.

Yes

No

a.

Do all dependent children live in your household? If No, please explain:

b.

Do all dependent children depend solely on you for support? If No, please explain:

 

 

c.

If any dependent child is age 19 or older, is/are they regularly attending school? If No, please explain:

 

 

 

 

 

 

 

 

 

EOI

 

 

continued

GR-67853 (7-14)

Page 3 of 4

Employee/Member Social Security Number

B.Employee/Member: Complete this Section - Please print. (Continued)

3.Statement of Health for individual(s) listed above requesting coverage. Please answer the following questions to the best of your

knowledge and belief. If any of the following questions are checked “Yes”, you must provide details in Number 4 below.

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Is any individual pregnant? If Yes, Who:

 

 

 

 

 

 

 

Date Due:

 

 

 

Any pregnancy complications or problems? If Yes, explain:

 

 

 

 

 

 

 

b.

Has any individual used tobacco products in the last 12 months (cigarettes, cigar, pipe, chewing tobacco)?

 

 

If Yes, Who:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Are any inpatient or outpatient medical, surgical or diagnostic procedures recommended or contemplated: If Yes, When:

 

 

 

Individual:

 

 

 

 

 

 

 

 

 

Name of procedure:

 

 

 

Reason for procedure:

 

 

 

 

 

 

 

 

 

 

 

 

d.

In the past 7 years, has any individual been confined to a hospital, clinic, sanatorium, rehabilitation or other treatment facility?

 

 

If Yes, Who:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Why:

 

 

 

 

 

 

 

 

 

When:

 

e.

In the past 7 years, has any individual been examined, monitored or received medical treatment from any doctor, practitioner or

 

 

counselor for any condition other than minor illnesses (cold, flu, etc.)?

 

 

 

 

 

 

 

 

If Yes, Who:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Why:

 

 

 

 

 

 

 

 

 

When:

 

f.

Is any individual(s) currently taking medication(s)? If Yes, complete the following information:

 

 

 

 

 

 

 

Name of Individual

Medication

 

Dosage/Frequency

Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g.Within the past 10 years, have you, your spouse or child(ren) had any disease, impairment of or treatment (other than minor illnesses) for any of the following? If Yes, check the appropriate box(es) and provide details in Number 4.

AIDS*

Cancer

Immune System Disorder

Nervous System

Arthritis Type:

 

 

Carpal Tunnel Syndrome

Intestine/Stomach/Ulcer

Paralysis/Paresis

Asthma/Emphysema/COPD

Chest Pain

Kidney/Bladder

Reproductive System

Back/Spine/Neck

Chronic Fatigue/Fibromyalgia

Liver/Spleen/Pancreas

Skin Disorder

Blood Disorder/Bleeding/Blood Clot

Diabetes/Metabolic

Lungs/Breathing

Stroke

Blood Pressure/Hypertension

Ears/Eyes

Lupus Type:

 

 

Substance Abuse (Alcohol/Drug)

Blood Vessels/Circulation

Epilepsy/Seizure

Mental/Emotional Condition

Throat/Tonsils/Swallowing

Bones/Joints

Esophagus/Digestion/GERD

Multiple Sclerosis

Thyroid/Pituitary/Adrenal

Brain

Heart

Muscular Condition

Tumor/Growth

Other

 

 

 

 

 

 

*AIDS (Acquired Immune Deficiency Syndrome) is a serious disease. It is caused by a virus called HIV (Human Immunodeficiency Virus). The virus is found in some human body fluids of infected people, most notably in semen and blood. If the AIDS virus finds its way into the bloodstream, it can damage the body’s defenses against disease, resulting in life- threatening diseases. There is no known cure.

4.In the space below, describe all conditions checked in 3g above and provide additional information for questions 2a-c and 3a-f, if needed.

Ques.

Name of

 

 

Date of

Details/

Treatments

Full Recovery Date

No.

Individual

Diagnosis

Onset

Symptoms

Received

or is condition ongoing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if you are providing additional information on a separate attachment.

Certification: I certify these answers and statements are complete and true to the best of my knowledge and belief. I will inform Aetna of any material changes to the information provided which take place between the time the form is completed and the time coverage becomes effective. I agree that this document shall become a part of my request for group coverage and I acknowledge that I have retained a copy of this document as completed by me.

Acknowledgment: I understand that, to the extent permitted by state law, false statements may result in the denial of claims or in my insurance coverage being void as of its effective date with no benefits payable. I understand that conditions which are disclosed on this form may be subject to all conditions of my Plan Sponsor’s Plan including any preexisting condition limitations, fraud provisions and employee actively at work and dependent health condition requirements. My signature indicates that I have reviewed all information and statements on this form for completeness and accuracy.

Authorization: To all physicians and other health professionals, hospitals and other health care institutions, insurers, medical or hospital service and prepaid health plans, employers and

the Medical Information Bureau: You are authorized to provide Aetna Life Insurance Company (Aetna) information concerning healthcare, advice, treatment or supplies (including those related to mental illness and/or AIDS/ARC/HIV) provided me or any members of my family for whom coverage has been requested. (Minnesota residents are not required to provide information concerning results of AIDS/ARC/HIV tests performed on a criminal offender or a crime victim.) I acknowledge that information obtained from any or all of the above may result in further underwriting investigation. This information will be used for the purpose of determining eligibility for coverage. This authorization will be valid for twelve (12) months from the date signed. I acknowledge that I have read the Privacy Notice and Misrepresentation section shown on “Page 2 of 4” of this form and know that I have a right to receive a copy of this authorization upon request. I agree that a photographic copy of this authorization is as valid as the original.

Employee/Member’s or Authorized Person’s Signature (Required at all times)

Date

Spouse’s or Authorized Person’s Signature (Required if spouse coverage is requested)

Date

GR-67853 (7-14)

Page 4 of 4
Get Aetna Evidence Of Insurability PDF Form

Form Characteristics

Fact Name Details
Purpose of the Form The Aetna Evidence of Insurability form is required for individuals seeking Life and Disability coverage. It helps Aetna evaluate and approve the insurance requests based on health information.
Completion Requirements Both the Plan Sponsor and the Employee/Member must thoroughly complete their respective sections. Incomplete forms may lead to processing delays.
Health Information Disclosure By completing the form, individuals authorize Aetna to access their health information. This may include additional inquiries or physical examinations if necessary.
Submission Methods The completed form must be submitted via mail or fax. For applications within the U.S., faxing is possible at 1-800-792-9710 while international applications can be sent to 1-402-474-8426.
Notification of Decision Aetna will inform the Plan Sponsor about the coverage approval. If coverage is denied, the Employee/Member will be notified directly.
State-Specific Regulations Each state has laws governing insurance applications. For instance, in Florida, knowingly providing false information can result in felony charges. Be sure to consider local law when submitting your form.

Guidelines on Utilizing Aetna Evidence Of Insurability

Completing the Aetna Evidence of Insurability form is an important step in securing your life and disability coverage. After submission, Aetna may reach out for any additional information needed to process your request. Follow the steps outlined below to ensure that your form is filled out correctly and completely.

  1. Section A: Plan Sponsor (Employer) Information
    • Enter the Control Number, Suffix, and Account numbers.
    • Provide the Employee/Member’s Social Security Number.
    • Fill in both your name and address as the Plan Sponsor.
    • Provide the Employee/Member’s name and address.
    • Add the telephone number of your authorized representative.
    • Include the Employee/Member's date of hire and both home and work telephone numbers.
    • Fill in your and the Employee/Member’s email addresses.
    • Complete the Employee/Member’s Annual Earnings.
    • Check the appropriate box(es) for Life coverage requests and provide existing and new coverage amounts.
    • Indicate the reason for the requested Life coverage.
    • Check the appropriate Disability box(es) and provide the coverage amounts or percentages.
    • Sign Section A as the Authorized Representative.
  2. Section B: Employee/Member Information
    • Verify that your name, address, and Social Security Number are correct.
    • List only those individuals seeking coverage.
    • Provide height and weight; this is required for processing.
    • Check the boxes related to dependent child coverage, if applicable.
    • Provide any required details for checked health conditions.
    • Sign the form, and if requesting spouse coverage, the spouse must sign as well.
  3. Submission
    • Make a copy of the completed form for your records.
    • Mail the original to Aetna Life Insurance Company at the specified address.
    • Alternatively, you may fax the form to the appropriate number based on your location.

Once you have filled out the form completely, submit it either by mailing it or via fax. After your submission, Aetna will notify you of their decision regarding the coverage. If any information is missing or incorrect, the processing may be delayed, so double-check your entries before finalizing your submission.

What You Should Know About This Form

What is the purpose of the Aetna Evidence of Insurability form?

The Aetna Evidence of Insurability (EOI) form is used to assess an individual's health status when applying for life and disability insurance coverage. It is a requirement to provide detailed health information, which helps Aetna determine the eligibility for coverage. The completed form enables Aetna to evaluate risks and decide on the approval of insurance benefits based on the information provided.

What should a Plan Sponsor include in Section A of the form?

In Section A, the Plan Sponsor must provide comprehensive information about the employee or member requesting coverage. This includes the Control Number, Suffix, and Account numbers, as well as the employee's Social Security Number. It is essential to accurately fill out personal details such as names, addresses, contact numbers, and email addresses. Additionally, the Plan Sponsor is responsible for checking the coverage options that apply, including existing coverage amounts and any new amounts requested, along with the reasons for the requested life and disability coverage.

What must the employee or member do in Section B of the form?

The employee or member must carefully complete Section B, providing accurate personal details and health information. They should list only the individuals requesting coverage and answer all health-related questions to the best of their knowledge. If there are any changes in health after submitting the form, the employee must inform Aetna. It is crucial to read the privacy notice and sign the form to certify the accuracy of all provided information before submission.

What happens after the form is submitted to Aetna?

Once the form is submitted, Aetna will review the information provided. If additional details or a physical examination are needed, Aetna will contact the applicant directly. The decision regarding coverage will be communicated to the employee or member. If coverage is denied, the employee/member will receive notification directly. It is important to note that if the form is incomplete or not signed, processing may be delayed.

Common mistakes

Filling out the Aetna Evidence of Insurability form accurately is crucial to ensure a smooth application process for life and disability coverage. However, many individuals make common mistakes that can lead to complications or delays. Here are five significant errors to avoid.

One frequent mistake is the failure to complete all sections of the form. Each part must be filled out completely; otherwise, the form may be returned unprocessed. For instance, neglecting to include the Employee/Member's Social Security Number can set back the entire application process. Ensure that every box is checked and every line is filled to avoid unnecessary delays.

Inaccuracies in personal details are another typical error. This includes incorrect names, addresses, or Social Security Numbers. Such errors not only jeopardize the approval of coverage but can also create issues if Aetna needs to reach the applicant for further inquiries or information. Double-checking your information before submitting the form is essential.

Individuals also often overlook the need for accurate height and weight measures. Not providing these details can result in a delay, as the form will be returned unprocessed. These figures are critical for assessing health risks and determining insurability, so they must be precise and up-to-date.

Checking the wrong boxes regarding coverage can cause serious misunderstandings. Applicants must take care when indicating the types of coverage sought, particularly for dependents. If the appropriate boxes are not checked, Aetna may assume that coverage is not intended for certain individuals, potentially leading to gaps in protection.

Lastly, failing to sign the form is a common, but easily avoidable, mistake. Both the employee/member and their spouse, if applicable, must provide their signatures. Without these, Aetna cannot process the application, and it will remain in limbo until all necessary signatures are obtained. This can significantly delay the initiation of coverage.

Being diligent about these common pitfalls will aid in smooth processing and can prevent unnecessary complications in securing essential insurance coverage.

Documents used along the form

The Aetna Evidence of Insurability form is an essential step in applying for life and disability insurance. To ensure a smooth application process, several other documents and forms are commonly used alongside this form. Below is a brief description of four key documents that may be required.

  • Medical Release Authorization: This document permits Aetna to obtain your medical records from healthcare providers. It's crucial for verifying the information provided in the Evidence of Insurability form and may be necessary for underwriting purposes.
  • Employer Verification Form: Often required by Aetna, this form confirms employment status and details regarding the coverage requested. It ensures that all information is accurate and up-to-date before processing the application.
  • HIPAA Authorization Form: This form allows your health information to be shared in compliance with healthcare privacy laws. It is designed to protect your personal health information while enabling the insurance company to access necessary details for underwriting.
  • Claim Form (if applicable): This form is used to initiate a claim once coverage is approved and may be necessary if the insured event occurs. It includes important details regarding the claim process and required documentation for benefits payout.

Having these documents ready can mitigate delays during the coverage approval process. Ensuring accuracy and completeness will facilitate a timely review by Aetna, allowing access to essential coverage when it's needed most.

Similar forms

  • Health Insurance Application Form: Much like the Aetna Evidence of Insurability form, this document requires individuals to disclose their health status and history. The insurance company uses this information to assess eligibility for coverage.
  • Life Insurance Application: Similar to the Aetna form, a life insurance application typically requests details about an individual’s health and lifestyle. It helps insurers evaluate the risks associated with providing life coverage.
  • Disability Insurance Application: This form evaluates the applicant's current health and any previous disabilities, just as the Aetna Evidence of Insurability assesses the individual for life and disability coverage. Both forms aim to determine eligibility based on health conditions.
  • Medicare Enrollment Form: When applying for Medicare, beneficiaries provide detailed health information, much like the Aetna form. This enables the program to tailor benefits according to the individual’s medical needs.
  • Long-Term Care Insurance Application: In this application, individuals are required to disclose their health status similarly to the Aetna form. This information allows insurers to determine the necessary care and coverage levels for applicants.
  • Critical Illness Insurance Application: This document is comparable to the Aetna Evidence of Insurability form in that it requires applicants to detail health issues. The insurer needs these insights to evaluate risk factors and set coverage terms.

Dos and Don'ts

When filling out the Aetna Evidence of Insurability form, there are important steps to ensure everything is completed accurately. Below is a list of things you should and shouldn’t do:

  • Do: Verify that all personal information such as name, address, and Social Security Number are complete and accurate.
  • Do: Read the Privacy Notice and Misrepresentation section before completing the form.
  • Do: Include height and weight information; missing details will result in the form being returned unprocessed.
  • Do: Sign and date the form, and ensure it is submitted confidentially.
  • Do: Provide a copy of the form for your records after submission.
  • Do: Provide complete and accurate health information, including any changes that occur after submitting the form.
  • Don't: Leave any sections incomplete, as this will delay processing.
  • Don't: Provide false or misleading information; this can result in penalties or denial of coverage.
  • Don't: Forget to include the required reason for requesting life coverage.
  • Don't: Neglect to check the appropriate coverage boxes for the individual(s) requesting insurance.
  • Don't: Submit the form without ensuring your authorized representative has signed it, if required.
  • Don't: Rely solely on the information provided in the form without reviewing it for accuracy and completeness.

Misconceptions

  • Misconception 1: The form is optional for applicants.

    • The Aetna Evidence of Insurability form is not optional if you are requesting additional life or disability coverage. Completing this form is a necessary step in the evaluation process.

  • Misconception 2: It's sufficient to provide basic information.

    • Simply providing basic information is not enough. It's crucial to complete all sections of the form accurately, or it may be returned unprocessed.

  • Misconception 3: Submission of the form guarantees coverage.

    • Submitting the form does not guarantee that coverage will be approved. Aetna will review the details and make a decision based on the provided information and their underwriting guidelines.

  • Misconception 4: Only medical history matters.

    • While medical history is important, the form also requires other details, such as your annual earnings and contact information. All requested information must be provided for a thorough evaluation.

  • Misconception 5: You cannot amend the form after submission.

    • You should inform Aetna of any health changes or inaccuracies in the information provided after submitting the form. Failing to do this might impact your coverage approval.

Key takeaways

Key Insights for Completing the Aetna Evidence of Insurability Form:

  • Accuracy is Crucial: Ensure all personal information, like names and Social Security Numbers, are filled in correctly to avoid processing delays.
  • Health Details Matter: Be honest and thorough when providing health history. Incomplete information can lead to rejection of your application.
  • Consult the Employer: Plan sponsors need to complete their section carefully, including coverage amounts and relevant dates. This sets the stage for a smooth process.
  • Obtain Copies: Always make a copy of your completed form for your records before submitting it. This keeps you informed about what you disclosed.
  • Understand Your Rights: Familiarize yourself with your rights regarding your personal information and the importance of accurate disclosures, as misrepresentation can have serious consequences.

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