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SI 9340-377661 1 of 2 (10/13) Public Employees Benefits Board (PEBB) Program Underwritten by Standard Insurance Company Long Term Disability (LTD) Evidence of Insurability Form Use this form if applying for long term disability insurance that requires approval from Standard Insurance Company. Type or print clearly in ink. Complete Sections 1 – 4 below. Read the Information Practices Notice at the end of this form. Return this completed form to Standard (see address on next page). SECTION 1: EMPLOYEE PERSONAL INFORMATION Social Security Number Last Name First Name M.I. Employee I.D. Number Street Address City State ZIP Code + 4 Agency Name Agency Code Date of Birth Male Female Phone Number – Daytime ( ) Phone Number – Evening ( ) Occupation Salary SECTION 2: TYPE OF ENROLLMENT/CHANGE THAT REQUIRES APPROVAL I wish to: Enroll in the optional LTD plan after 31 days of becoming newly eligible for PEBB coverage; choose a waiting period. Decrease the waiting period for optional LTD coverage; choose a waiting period. Choose a waiting period: 30 days 60 days 90 days 120 days 180 days 240 days 300 days 360 days SECTION 3: EVIDENCE OF INSURABILITY INFORMATION Check yes or no for each question, and give details for any “yes” answers on page 2. 1. Have you had any physical, mental, or emotional condition, injury, sickness, or surgery in the past 5 years? 2. Have you consulted or been attended by a physician or practitioner for any cause in the past 5 years? 3. Are you now unable to work full-time because of any physical, mental, or emotional condition, injury, or sickness? 4. Has a medical professional ever treated you for, diagnosed you as having, or prescribed medication for you for any of the following: a. High blood pressure, cardiovascular disease, heart ailment, arteriosclerosis, or stroke? b. Mental condition, depression, epilepsy, or nervous system disorder? c. Cancer, diabetes, or nephritis? d. Arthritis, strained or injured back, slipped disc, or any bone, joint, or muscle disorder? e. Lung, kidney, stomach, genital, urinary, liver, pancreas, or intestinal ailment? f. Blindness or deafness? g. An immune system disorder not related to Human Immunodeficiency Virus (HIV)? 5. Has a medical professional ever diagnosed you as having or prescribed medication to you for Acquired Immune Deficiency (AIDS), AIDS-Related Complex (ARC), or HIV infection? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 6. Have you sought or received advice or treatment for the use of alcohol or drugs in the past 10 years? 7. In the past 10 years have you had a persistent cough, unintentional weight loss of 10 pounds or more, persistent fatigue, persistent node enlargement, prolonged night sweats, pneumonia, lesions or growth? 8. Do you take medication for any physical, mental or emotional condition, injury, or sickness? 9. Do you plan any operation or visit to the doctor or practitioner for an existing physical, mental or emotional condition, injury, or sickness? 10. Have you ever been declined for insurance or offered a rated or restricted policy, either as a new policy or reinstatement? 11. Are you now pregnant? Height: Weight: Yes No Yes No Yes No Yes No Yes No Yes No Physician or Medical Facility with Applicant’s Complete Medical Records Phone / State / Zip: continued on back Reset ---PAGE BREAK--- SI 9340-377661 2 of 2 (10/13) Provide details for any “yes” answers below. Use a separate sheet if needed. Question Number Description of Injuries, Disorders, and Operations Month/Year Duration Final Result Health Care Providers Consulted Address/City/State SECTION 4: ACKNOWLEDGEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION Employee’s signature (required) Date PEBB LONG TERM DISABILITY INSURANCE CONTRACTOR - Standard Insurance Company Attn: Medical Underwriting Department, 900 SW Fifth Avenue, Portland, OR 97204-1282 Phone: 1-[PHONE REDACTED] Information Practices Notice To help us determine your eligibility for group insurance we may request information about you from other people and organizations. For example, we may request information from your doctor or hospital, other insurance companies, or MIB, Inc. (MIB), formerly known as Medical Information Bureau. We will use the authorization you signed on this form when we seek this information. MIB -Information regarding your insurability will be treated as confidential. Standard Insurance Company or its reinsurers may, however, make a brief report thereon to the MIB, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its Members. If you apply to another MIB Member company for life or health (including short and long term disability ) insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at [PHONE REDACTED] (TTY [PHONE REDACTED]). If you question the accuracy of 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. Standard Insurance Company may release information in its file to its reinsurers, and Standard Insurance Company, or its reinsurers, may release information in its file to other insurance companies to whom you may apply for life or health (including short and long term disability) insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com. DISCLOSURE TO OTHERS – The information collected about you is confidential. We will not release any information about you without your authorization, except to the extent necessary to conduct our business or as required or permitted by law. YOUR RIGHTS - You have a right to know what information we have about you in our underwriting file. You also have a right to ask us to correct any information you think is incorrect. We will carefully review your request and make changes when justified. If you would like more information about this right or our information practices, please contact us at: Medical Underwriting, Standard Insurance Company, 900 SW Fifth Avenue, Portland, Oregon 97204- 1282 or call 1-[PHONE REDACTED]. FRAUD NOTICE - Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed. I UNDERSTAND AND AUTHORIZE THE FOLLOWING: I represent that the information I provide to Standard Insurance Company (The Standard) is true and complete. I understand that The Standard relies on the truthfulness of my information to decide if I qualify for optional long term disability insurance coverage. If I provide false or incomplete information which is material to The Standard’s decision about my coverage, The Standard may rescind my insurance coverage and/or deny claim payments. I agree to notify The Standard if my medical condition changes while this application is pending. If Standard approves my application, the Group Policy will determine my insurance coverage including coverage start date. I must meet any Group Policy Active Work Requirement to become insured. If Standard denies my application, their liability is limited to a refund of premium that I may have paid. To any health plan, health care provider or facility, pharmacy, laboratory, insurance or reinsurance company, and the MIB Inc. (MIB): I instruct you to release my entire medical records and other protected health information (except for notes) to The Standard or its reinsurers. This includes information on 1) any disorder of the immune system, including Acquired Immune Deficiency (AIDS) or other related or complexes; 2) any communicable or sexually transmitted disease or disorder; and 3) the diagnosis and treatment of mental illness and the use of alcohol, drugs and tobacco. This replaces any previous agreements I have made to limit the release of my protected health information. The Standard will use information obtained about me to decide my eligibility for optional long term disability insurance coverage. The Standard may share information it has about me to 1) reinsurers; 2) persons performing services for The Standard regarding my application; 3) the MIB, to report to the MIB information exchange and for MIB to audit The Standard’s reporting; 4) other insurance companies I have applied for insurance coverage or benefits; and 5) others with my authorization or otherwise permitted by law. The Privacy Rule under the Health Insurance Portability and Accountability Act (HIPAA) does not apply to disability insurance coverage, and does not protect the release of information to The Standard. I have received and read the Information Practices Notice and Fraud Notice on the back of this form. I have kept a copy of this form for my records. I may receive a copy of this form from The Standard at any time. This authorization will remain valid for six months from the date of my signature below. A copy or fax of this authorization is as valid as the original. I may refuse to sign this form or revoke it at any time by sending a written request to The Standard, However, if I do, The Standard may deny coverage. My revocation does not apply until after received by The Standard. Print and Sign