Read EOI_Licensee_and_RMHC.pdf text version

Minnesota Life Insurance Company

Evidence of Insurability Instructions

1. This Evidence of insurability (EOI) form should already have your Employer's Name and the Group Number(s) preprinted on it. If this is not the case, check with Mercer Administration regarding your plan's Group Number. We cannot process your request for coverage without your Group Number. 2. If you are applying for life coverage, Mercer Administration should indicate your current amount, the total amount you are requesting (including your current amount and any guaranteed amount, if applicable) and the amount that needs to be medically underwritten in the coverage information section on the back of the EOI form or should give you instructions regarding what these amount should be. If you have a question regarding the amount that requires underwriting, please contact Mercer Administration. IMPORTANT: The "amount to be underwritten" is the dollar amount of coverage for which you or your dependents must show proof of good health. This "underwritten" amount should not include any coverage you or your dependents may already have in force through this plan or any coverage that can be obtained through this plan without providing evidence of insurability. If the amount to be underwritten is incorrectly stated on your EOI form, your or your spouse may be asked to have an exam, blood profile or EKG that might otherwise not be necessary. Note: If there is no current coverage in force, state "0" in that column. Current, total and underwritten amounts need only be indicated on this EOI form for the family members who are applying for coverage at this time. If not applying, that amounts in these columns can be left blank. 3. Make sure that you give us all of the requested information. Answer all questions. Sign and date the Evidence form at the bottom. Failure to do so may result in having your Evidence Form returned to you for completion and will definitely delay processing time for your request. 4. Complete both sides of the Evidence Form. 5. Indicate the full names and complete mailing addresses of the physicians listed. Attach an additional sheet, if necessary. Complete mailing addresses will greatly reduce processing delays. 6. Make and keep a copy of both sides of the Evidence Form for your records. 7. Read the Minnesota Life Consumer Privacy Notice on the back page of the EOI form. 8. After completing your Evidence Form, send the completed form (both sides) to the appropriate address below:

McDonald's Licensees Health & Welfare Plan c/o Mercer Administration P.O. Box 4548 Iowa City, IA 52244-4548 Ronald McDonald House Charities Health & Welfare Plan c/o Mercer Administration P.O. Box 4548 Iowa City, IA 52244-4548

9. For general questions regarding completing this form, please call Mercer Administration at 1-866-881-6646, or for checking the status of your underwriting once the EOI form has been submitted to Minnesota Life, please call Medical Underwriting at 1-800-872-2214. However, you must contact Mercer Administration if you have a question regarding amounts. Medical Underwriting does not have information concerning the amount that should be indicated on your EOI form.

Any person who, with intent to defraud or knowing that 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.

EdF65490 Rev 12-2006

abcd

FIRST NAME STREET ADDRESS DATE OF BIRTH

Minnesota Life Insurance Company

A B1-3102 A400 Robert Street North A St. Paul, Minnesota 55101-2098 A Fax 651-665-7092

GROUP LIFE INSURANCE EVIDENCE OF INSURABILITY

EMPLOYER NAME: Please check the appropriate employer. POLICY NUMBER: 33240 McDonald's Licensees Health & Welfare Plan Ronald McDonald House Charities Health & Welfare Plan POLICY NUMBER: 33252 For questions regarding proper amount to be underwritten, contact Mercer Administration at 1-866-881-6646. Please type or print in ball point pen.

EMPLOYEE INFORMATION

MIDDLE INITI AL CITY SOCIAL SECURITY NUMBER DATE OF EMPLOYMENT LAST NAME EMAIL ADDRESS STATE ANNUAL SALARY ZIP CODE GENDER MALE TOTAL AMOUNT OF INSURANCE REQUESTED FEMALE

No change

FIRST NAME

Basic Life $

MIDDLE INITI AL LAST NAME

Optional Life $

EMAIL ADDRESS

SPOUSE INFORMATION

DATE OF BIRTH SOCIAL SECURITY NUMBER GENDER MALE TOTAL AMOUNT OF SPOUSE LIFE INSURANCE REQUESTED FEMALE

No change

$

CHILDREN INFORMATION - (list names and dates of birth for your eligible children)

NOTE: If you are requesting coverage for a stepchild or a child over age 18, please check with Mercer Administration to make sure the child would qualify as an eligible dependent under the contract terms of the plan.

TOTAL AMOUNT OF CHILD LIFE INSURANCE REQUESTED

No change

$

HEALTH QUESTIONS - (must be answered for coverage that is not guaranteed)

EMPLOYEE YES NO SPOUSE YES NO CHILDREN YES NO EMPLOYEE HEIGHT WEIGHT SPOUSE HEIGHT WEIGHT OCCUPATION

1. During the past three years, have you for any reason consulted a physician(s) or other health care provider(s), or been hospitalized? 2. Have you ever had, or been treated for, any of the following: heart, lung, kidney, liver, nervous system, or mental disorder; high blood pressure; stroke; diabetes; cancer or tumor; drug or alcohol abuse including addiction? 3. Have you ever been treated or diagnosed by a physician as having Acquired Immune Deficiency Syndrome (AIDS), or any disorder of your immune system; or had any test showing evidence of antibodies to the AIDS virus (a positive HIV test)? If you answer yes to any question, give details including dates, names and addresses of doctors or hospitals, the reason for the visit or consultation, the diagnosis, and the treatment in the Additional Health Information section on the second page or on a separate sheet of paper. The answers provided on this application are representations of the person signing below. The answers given are true and complete. It is understood that Minnesota Life Insurance Company, (the Company), St. Paul, Minnesota 55101-2098 shall incur no liability because of this application unless and until it is approved by the Company and the first premium is paid while my health and other conditions affecting my insurability are as described in this application. I understand that false or incorrect answers to the above questions may lead to rescission of coverage. If coverage is rescinded, an otherwise valid claim will be denied. To determine my insurability or for claim purposes, I authorize any person(s), medical practitioner, institution, insurance company or Medical Information Bureau (MIB) to give any medical or nonmedical information about me including alcohol or drug abuse, to the Company and its reinsurers. I authorize all said sources, except MIB, to give such information to any agency employed by the Company to collect and transmit such information. I understand in determining eligibility for insurance or benefits, this information may be made available to underwriting, claims, medical and support staff of the Company. If I do not revoke this authorization, it will be valid for 24 months from the date I sign it. A photocopy shall be as valid as the original. I have read this Authorization and the Consumer Privacy Notice on the second page, and I understand that I can have copies.

EMPLOYEE SIGNATURE DAYTIME TELEPHONE NUMBER EVENING TELEPHONE NUMBER DATE SIGNED

X

SPOUSE SIGNATURE DAYTIME TELEPHONE NUMBER EVENING TELEPHONE NUMBER DATE SIGNED EdF65490 Rev 12-2006

X

03-30567.12

CONSUMER PRIVACY NOTICE

To underwrite your insurance request, the Company may ask for additional personal information, such as an insurance medical exam; lab tests; medical records from your insurance company, physician or hospital; a report from the Medical Information Bureau (MIB), a non-profit organization of life insurance companies that exchanges information among its members. Information about your insurability is confidential. Without your express authorization, the Company or its reinsurers may send your information to government agencies that regulate insurance; or, without identifying you, to insurance organizations for statistical studies; or may make a brief report of health information to the MIB. If you apply to a MIB member company for life or health insurance, or submit a benefits claim for benefits to a member company, the MIB, upon request, will supply the member company with the information in its file. You or your authorized representative have the right to: receive by mail or to copy your personal information in the Company or MIB files, including the source and who received copies within the past two years; to correct or amend personal information in these files; to know specific reasons why coverage was not issued as applied for; and to revoke your authorization at any time. At your written request, within 30 days the Company will explain in writing how to learn what is in your file, its source, how to correct or amend it or how to learn why coverage was not issued as applied for. You can send a written statement as to why you disagree. If we correct or amend the information, we will notify you and anyone who may have received the information. If we do not agree with your statement, we will notify you and keep your statement in your file. For further information about your file or your rights, For information about the Medical Information Bureau, you may contact: you may contact: Group Division Underwriting Medical Information Bureau Information Office Minnesota Life Insurance Company P.O. Box 105, Essex Station 400 Robert Street North Boston, Massachusetts 02112 St. Paul, Minnesota 55101-2098 MIB Telephone: (866) 692-6901 Telephone: (800) 872-2214 MIB TTY: (866) 346-3642

ADDITIONAL HEALTH INFORMATION

NAME DATE NAME AND ADDRESS OF DOCTOR, CLINIC, HOSPITAL REASON FOR CONSULTATION DIAGNOSIS AND TREATMENT

COVERAGE INFORMATION

POLICY NUMBER: Please check the appropriate number. 33240 (McDL) 33252 (RMHC)

For life coverages: Enter the dollar amount of current coverage (including any guaranteed amount, if applicable), the total dollar amount desired and the dollar amount of the difference between the total amount desired and the current amount which requires proof of good health at this time (i.e. needs to be medically underwritten).

Current Amount Total Amount Desired Amount to be Underwritten

Employee: Spouse Child(ren):

Basic Life Supplemental Life Supplemental Life Life

$ $ $ $ New Hire

$ $ $ $ Late Entrant Increase

$ $ $ $ Other - Explain:

EdF65490 Rev 12-2006

This EOI submitted due to:

03-30567.12

Initial Enrollment

Information

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