CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Evidence of Insurability (EOI) / Coverage Election Summary form

This document is an Evidence of Insurability application and Coverage Election Summary used by group administrators/employers and applicants to request or change life, disability, and critical illness coverages with Dearborn Life Insurance Company for Blue Cross Blue Shield - Oklahoma groups.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEvidence of Insurability (EOI) / Coverage Election Summary form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach this form with the completed Employee Application and return to Dearborn Life Insurance Company; do not deduct premiums for coverage subject to EOI until approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecovered by the form (life, disability, critical illness)

medical underwritingmedical underwriting routed to

7y/5y/6mhealth question lookback

24 monthsauthorization expiration

(888) 381-9727phone

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Evidence of Insurability & Underwriting Criteria

EOI submission and health criteria

Underwriting and evidence of insurability requirements for requested coverage amounts and status changes.

ALL of the following

Application completeness
- All pages of the application must be completed; omitted information will cause consideration of coverage to be delayed.
Submission and routing
- Attach this form with the completed Employee Application and return to Dearborn Life Insurance Company, Attn: Medical Underwriting Department, P.O. Box 7072, Downers Grove, IL 60515.
Premium withholding
- Do not deduct premiums for any coverage subject to evidence of insurability until final confirmation of approval is received.
Coverage amounts reported
- Form must report current amount in force, additional amount requested, and total amount requested for each applicable benefit type (basic and supplemental/voluntary term life; spouse term life; short-term and long-term disability; critical illness).
  See the coverage amount fields on the form for each benefit type.
Health questions and detail requirement
- Applicant must answer all specified health questions; any 'Yes' answers require details to be provided on the designated details section(s) of the form.
- Health questions include lookback periods: generally 7 years for many conditions, 5 years for substance misuse/treatment, 6 months for recent hospitalizations/procedures, and tobacco use in the last 2 years.
Consequences of incomplete or false information
- Omitted information will delay consideration of coverage; failure to provide full information or providing false information may result in denial of benefits or possible investigation for fraud.

Health questionnaire specifics

Questions ask about a range of conditions in the past 7 years, including cardiac conditions (congestive heart failure, heart attack), stroke/paralysis, liver disease, emphysema/COPD; AIDS/ARC/HIV; Hodgkin's disease, leukemia, lymphoma, malignant brain tumor; chronic kidney disease, dialysis or transplant; neurological or muscular disorders; cancer, tumors, high blood pressure, TIA, aneurysm, neurological or circulatory disorders; diabetes, autoimmune disorders, blood disorders; gastrointestinal, respiratory, genitourinary, musculoskeletal or connective tissue disorders; depression, anxiety or other mental/nervous disorders.
Additional disability-specific health questions ask about pregnancy and musculoskeletal disorders (back, spine, joints, arthritis, fibromyalgia, chronic fatigue, etc.).
Questions for the past 5 years ask about medical advice, treatment for drug or alcohol abuse, use of controlled substances (except prescribed), or convictions/charges for driving under the influence.
Questions for the past 6 months ask about hospitalization, advice to have surgery, diagnostic tests or other evaluation, and prescription of long-term maintenance medications for chronic conditions.

Documentation for 'Yes' answers

Provide details for any 'Yes' answers in the sections provided (physician/contact and treatment information) using the multiple detail lines/pages included on the form.

Actions for Employers / Group Administrators

Documentation Required

Submission and premium withholding instruction

Attach this form with the completed Employee Application and return to Dearborn Life Insurance Company, Attn: Medical Underwriting Department, P.O. Box 7072, Downers Grove, IL 60515. Do not deduct premiums for any coverage subject to evidence of insurability until Dearborn Life Insurance Company provides final confirmation of approval.

Submit the completed form with employer/employee enrollment information to the Medical Underwriting Department at the address above.
Employer must not withhold or deduct premiums for amounts subject to EOI until final approval is received.

Documentation Required

Medical Records Release and Authorization

The applicant authorizes any physician, medical professional, hospital, clinic, pharmacy, laboratory, insurance company, the MIB, Inc. and other covered entities or health plans to disclose medical records and related information to Dearborn Life Insurance Company's underwriting department and its authorized representatives; this authorization may be revoked in writing but does not affect disclosures already made and expires 24 months from the date signed.

Form Fields, Coverage Types, and Lookback Periods

Applicant / Employee information

Employee full nameFirst, MI, Last (Employee) collected on form

SSN / Alternate IDSocial Security Number and Alternate ID fields for routing and identification

Contact detailsHome mailing address, city, state, zip, preferred contact method, telephone, cell, work, and email

Date of birthDate of Birth (MM/DD/YYYY) for employee and spouse

OccupationOccupation field for underwriting assessment

Spouse/partner detailsSpouse name, DOB, SSN, contact numbers, email, state/country of birth (completed if spouse coverage requested)

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyEvidence of Insurability (EOI) / Coverage Election Summary form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionAttach this form with the completed Employee Application and return to Dearborn Life Insurance Company; do not deduct premiums for coverage subject to EOI until approval.

SourceLink

On This Page

Question asks whether applicant has used cigarettes or other tobacco in the last 2 years.

Authorization covers medical history, pharmaceutical history, drug or alcohol use or abuse, mental illness, HIV and other sexually transmitted diseases.

Revocation must be in writing and will not affect prior disclosures.

Note

Disclosure to Reinsurers and MIB

Dearborn Life Insurance Company may disclose information obtained in considering the application to its reinsurers and to the MIB, Inc.; a photocopy of the authorization is as valid as the original.

Information provided pursuant to this authorization may be re‑disclosed and lose federal privacy protections.
Retain a duplicate copy of the authorization for your records.

Coverage types listed

Basic Term LifeCurrent, Additional, and Total Amount fields present on form

Supplemental/Voluntary Employee Term LifeCurrent, Additional, and Total Amount fields present on form

Supplemental/Voluntary Spouse Term LifeCurrent, Additional, and Total Amount fields present on form

Short-Term Disability (Basic and Voluntary)Current, Additional, and Total Amount fields for basic and voluntary short-term disability

Long-Term Disability (Basic and Voluntary)Current, Additional, and Total Amount fields for basic and voluntary long-term disability

Critical Illness (Employee and Spouse)Current, Additional, and Total Amount fields for employee and spouse critical illness

Health lookback periods

7-year lookbackHealth questions ask if diagnosed, treated, or given medical advice in the past 7 years for many listed conditions

5-year lookbackQuestions ask about medical advice, treatment, or substance misuse in the past 5 years

6-month lookbackQuestions ask if hospitalized, advised to have surgery, tests, or prescribed long-term maintenance medications in the past 6 months

2-year tobacco periodForm asks about cigarette or other tobacco use in the last 2 years

Authorization to release medical information

Authorization scopeApplicant authorizes physicians, medical providers, pharmacies, labs, insurance companies, the MIB, Inc., and other covered entities to disclose medical records to Dearborn Life Insurance Company's underwriting department

Revocation and effectAuthorization may be revoked in writing but revocation does not affect disclosures made prior to receipt of revocation

ExpirationThis authorization shall expire 24 months from the date it is signed

Disclosure to reinsurers and MIBDearborn Life Insurance Company may disclose obtained information to its reinsurers and the MIB, Inc.; a photocopy of the authorization is as valid as the original

MIB, Inc.

What MIB isMIB, Inc. is a not-for-profit membership organization of life insurance companies operating an information exchange on behalf of its members

Use in underwritingInformation from the MIB may be used by Dearborn Life Insurance Company in consideration of the application

Disclosure practiceApplicant authorizes disclosure to the MIB as part of the medical records and history release to Dearborn Life Insurance Company