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The Aetna Evidence of Insurability (EOI) form is a vital tool for individuals seeking life and disability coverage through Aetna Life Insurance Company. This form essentially serves to gather essential information about your health and demographic background, which will be used to assess eligibility for insurance coverage. It includes detailed instructions for both plan sponsors and employees or members applying for coverage. For example, plan sponsors must complete section A, ensuring all pertinent information such as control numbers, employee social security numbers, and contact details are accurately filled out. Meanwhile, employees or members must navigate section B, which requires providing personal health information, including height, weight, any medical conditions, and any medications currently taken. This thorough gathering of information is crucial because Aetna may ask for additional details or even require a physical examination. Importantly, the form also incorporates privacy and misrepresentation warnings to ensure that applicants are aware of the legal implications of providing false information. Proper completion and submission of the EOI form are essential steps toward securing the requested coverage and understanding your rights related to personal health information privacy.
Aetna Eoi 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
Please Print
Complete Section A in its entirety. Be sure that:
•All items are completed.
•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 (A6) and Employee/Member’s home and work telephone numbers (A7) are provided.
•Your Employee/Member’s and your
•Employee/Member’s Annual Earnings is completed (A10).
•You check the appropriate box(es) for individual(s) requesting Life coverage. Provide the current (existing) amount of coverage, requested additional (new) amount of coverage, resulting total amount of coverage and Guarantee Issue amount 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
Read the Privacy Notice and Misrepresentation section on “Page 2 of 4” of the Insurability Statement before completing.
Please Print
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.
Complete Section B. Be sure that:
•All items are completed.
•Only the names of individuals requesting coverage at this time are listed (B1).
•Height and Weight must be provided or this form will be returned unprocessed for your completion (B1).
•The appropriate boxes regarding dependent child coverage are checked, if applicable (B2a, B2b, and B2c).
•Complete dates and details are given for all conditions checked in B3g, (B4).
•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).
Make a copy for your records. If a final underwriting decision cannot be made within six months, Aetna reserves the right to request a new Evidence of Insurability Statement.
Please Note: If this form is not completed in its entirety and signed, it will be returned unprocessed for your completion.
EOI |
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Small Group |
Make a copy for your records. |
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, 151 Farmington Avenue, Hartford, CT
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 and Missouri 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 and may subject such person to criminal and civil penalties. 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 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 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. 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.
Employee/Member’s or Authorized Person’s Signature: |
Date: |
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Submission and Approval
The requested coverage will not be in effect unless and until evidence of insurability is submitted as required and is approved by Aetna.
Small Group Page 2 of 8 |
Evidence of Insurability Statement
Life and Disability Coverage
Aetna Life Insurance Company
A. Plan Sponsor: Complete this Section - Please print.
Make a copy for your records. Mail the original to:
Aetna Small Group
Underwriting
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Control Number |
Suffix |
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Account |
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2. Employee/Member Social Security Number |
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Plan Sponsor Name & Address |
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4. Employee/Member Name & Address |
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ATTN: |
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Plan Sponsor - Authorized Rep. Telephone Number |
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6. Employee/Member Date of Hire |
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7. Employee/Member Telephone Numbers (Including Area Code) |
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Plan Sponsor |
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Employee/Member’s Annual Earnings $ |
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11. |
Coverage(s) Applied for: |
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Life*
Employee/Member Basic Life Spouse
Employee/Member Supplemental, Optional or Voluntary Life Child(ren)
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Supplemental, |
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Optional or |
Spouse |
Child(ren) |
Basic Life |
Voluntary Life |
Life |
Life |
a. Current (Existing) Amount of Life Insurance Coverage? |
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b. Additional (New) Amount of Life Insurance Coverage requested? $ |
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c. Resulting Total Life Insurance Amount if Approved (a + b)? |
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d. Guarantee Issue Amount of Life Insurance? |
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*Reason for Requested Coverage (indicate all that apply). |
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Salary Increase |
Change in Multiple |
Late Applicant |
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Requesting an Amount in Excess of Plan’s Guaranteed Issue Limit |
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Disability Coverages (Employee/Member Only): |
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$
$
$
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Change in Increments Other (Please explain)
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Life Event/Status Change
Short Term Disability: |
Current Amount $ |
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Long Term Disability: |
Current Amount $ |
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Requested Amount $ |
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Requested Amount $ |
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12. 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 |
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Do all dependent children live in your household? If No, please explain: |
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Do all dependent children depend solely on you for support? If No, please explain: |
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If any dependent child is age 19 or older, is/are they regularly attending school? If No, please explain: |
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continued
EOI
Small Group Page 3 of 8 |
Employee/Member Social Security Number
B.Employee/Member: Complete this Section - Please print. (Continued)
3.Statement of Health for Individual(s) Listed Above. 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.
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Is any individual pregnant? If Yes, |
Who: |
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Date Due: |
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Any complications or problems? If Yes, explain: |
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Has any individual used tobacco products in the last 12 months (cigarettes, cigar, pipe, chewing tobacco)? |
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If Yes, Who: |
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Are any inpatient or outpatient medical, surgical or diagnostic procedures recommended or contemplated: If Yes, When: |
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Individual: |
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Name of procedure: |
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Reason for procedure: |
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In the past 7 years, has any individual been confined to a hospital, clinic, sanatorium, rehabilitation or other treatment facility? |
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If Yes, Who: |
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Why: |
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When: |
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In the past 7 years, has any individual been examined, monitored or received medical treatment from any doctor, practitioner or |
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counselor for any condition other than minor illnesses (cold, flu, etc.)? |
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If Yes, Who: |
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Why: |
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When: |
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Is any individual(s) currently taking medication(s)? If Yes, complete the following information: |
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Name of Individual |
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Medication |
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Dosage/Frequency |
Diagnosis |
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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 describe in Number 4.
AIDS* |
Cancer |
Immune System Disorder |
Nervous System |
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Arthritis Type: |
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Carpal Tunnel Syndrome |
Intestine/Stomach/Ulcer |
Paralysis/Paresis |
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Asthma/Emphysema/COPD |
Chest Pain |
Kidney/Bladder |
Reproductive System |
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Back/Spine/Neck |
Chronic Fatigue/Fibromyalgia |
Liver/Spleen/Pancreas |
Skin Disorder |
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Blood Disorder/Bleeding/Blood Clot |
Diabetes/Metabolic |
Lungs/Breathing |
Stroke |
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Blood Pressure/Hypertension |
Ears/Eyes |
Lupus Type: |
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Substance Abuse (Alcohol/Drug) |
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Blood Vessels/Circulation |
Epilepsy/Seizure |
Mental/Emotional Condition |
Throat/Tonsils/Swallowing |
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Bones/Joints |
Esophagus/Digestion/GERD |
Multiple Sclerosis |
Thyroid/Pituitary/Adrenal |
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Brain |
Heart |
Muscular Condition |
Tumor/Growth |
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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
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Name of |
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Date of |
Details/ |
Treatments |
Full Recovery Date |
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Diagnosis |
Onset |
Symptoms |
Received |
or is condition ongoing |
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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 |
Date |
Spouse’s or Authorized Person’s Signature (Required if spouse |
Date |
times) |
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coverage is requested) |
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Small Group Page 4 of 8 |
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids / services to people with disabilities and to people who need language assistance.
If you are an existing Aetna member and need a qualified interpreter, written information in other formats, translation or other services, please call the number on your member ID card. If you are a prospective Aetna member, please call
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
PO Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
Fax:
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, or at
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
Small Group Page 5 of 8 |
TTY: 711
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Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang
ᏩᎩᏍᏗ ᏚᏬᏂᎯᏍᏗ ᎤᏳᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ
Tajaajiiloota afaanii garuu bilisaa ati argaachuuf,bilbili
Voor gratis toegang tot taaldiensten, bell
Pou jwenn sèvis lang gratis, rele
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Για να επικοινωνήσετε χωρίς χρέωση με το κέντρο υποστήριξης πελατών στη γλώσσα σας, τηλεφωνήστε στον αριθμό
No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i kēia helu kelepona
Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu
Iji nwetaòhèrè na ọrụ gasị asụsụ n'efu, kpọọ
Tapno maaksesyo dagiti serbisio maipapan iti pagsasao nga awan ti bayadanyo, tawagan ti
Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi
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ເພອເຂາໃຊການບລການພາສາໂດຍບເສຍຄາຕກບທານ, ໃຫໂທຫາເບ |
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Nan etal nan jikin jiban ikijen Kajin ilo an ejelok onen nan kwe, kirlok
េដមបទទលបានេសវាកមភាសាែដលឥតគតៃថសរមាបេលាកអកើីួិ សមេហៅទរសពេទៅកាន់ូន័ូេលខ់
Të kɔɔr yïn wɛɛr̈ ̈de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke cɔl kɔc ye kɔc kuɔny ne nɔmba
For tilgang til kostnadsfri språktjenester, ring
Um Schprooch Services zu griege mitaus Koscht, ruff
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Para acessar os serviços de idiomas sem custo para você, ligue para
Pentru a accesa gratuit serviciile de limbă, apelați
Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону
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Heeba a nasta jangirde djey wolde wola chede bo apelou lamba
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ܬܝܐܢܓܡ ܐܢܫܠܒ ܐܬܪܝܗܕ ܐ̈ܬܡܠܚ ܠܥ |
ܢܘܬܝ̄ ܐܩܝܢܣ ܢܐ |
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หากทานตองการเขาถงการบรการทางดานภาษาโดยไมมคาใชจาย่้ ้ ึ ิ ้่ ีโปรดโทร่ ้
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File Breakdown
| Fact Name | Description |
|---|---|
| Form Purpose | The Aetna Evidence of Insurability (EOI) form is used to apply for life and disability insurance coverage. |
| Contact for Additional Information | Upon receipt of the completed EOI form, Aetna may contact applicants directly for further information. |
| State-Specific Compliance | This form is governed by state laws, ensuring compliance with regulations in each state where it is used. |
| Mandatory Information | Applicants must provide various details including Control Number, Social Security Number, and contact information. |
| Privacy Notice | A privacy notice outlines how personal information will be treated and maintained confidentially throughout the process. |
| Right to Access | Individuals have the right to access their personal data held by Aetna and request corrections if needed. |
| Fraud Warning | The form contains warnings against providing false information, which can result in legal consequences and penalties. |
| Submission Requirements | Incomplete or unsigned forms will be returned to the applicant, delaying the coverage decision process. |
| Follow-Up Procedure | If a final underwriting decision cannot be made within six months, Aetna may require a new EOI form. |
Guide to Using Aetna Eoi
After you gather all the necessary information, it’s time to fill out the Aetna Evidence of Insurability (EOI) form. Following these steps will help ensure that you complete the process smoothly and accurately.
- Plan Sponsor Section: Start by filling out Section A. Be sure to print clearly.
- Provide the Control Number, Suffix, and Account numbers in box A1.
- Enter the Employee/Member’s Social Security Number in box A2.
- Fill in both your name and address under boxes A3 and A4.
- Add your authorized representative’s telephone number in box A5.
- Input the Employee/Member’s date of hire in box A6.
- Complete the Employee/Member’s home and work telephone numbers in box A7.
- Include the email addresses in boxes A8 and A9.
- Enter the Employee/Member’s Annual Earnings in box A10.
- Check the necessary boxes in section A11 for the coverage types requested.
- Fill in the current and requested amounts for Life and Disability insurance under section A11.
- Make sure Section A is signed by your Authorized Representative in box A12.
- Hand the form over to the Employee/Member for their review.
- Employee/Member Section: Now, the Employee/Member should complete Section B. Again, print clearly.
- Verify that your name, address, and Social Security Number from Section A are correct.
- List only the individuals requesting coverage in box B1.
- Complete the height and weight fields for all individuals listed in box B1.
- Check the boxes regarding dependent child coverage in B2a, B2b, and B2c, if applicable.
- Provide complete dates and details for any health conditions checked in B3g and B4.
- Sign the form confirming all information is correct; if you are requesting coverage for a spouse, their signature is also necessary.
Make sure to keep a copy for your records. Once the form is submitted, Aetna will review it and may reach out for additional information. Stay tuned for their decision on the coverage.
Get Answers on Aetna Eoi
What is the Aetna EOI form?
The Aetna Evidence of Insurability (EOI) form is a document required by Aetna Life Insurance Company when an employee or member applies for life and disability coverage. It serves to assess the applicant's insurability by collecting detailed health information. This form must be carefully completed to ensure that the request for coverage is processed efficiently.
Who must complete the Aetna EOI form?
Both the plan sponsor and the employee or member must fill out specific sections of the EOI form. The plan sponsor completes Section A, providing necessary information about the group policy. The employee or member is responsible for completing Section B, which includes personal health information. Incomplete forms may delay processing or result in the form being returned.
What information is needed in Section A?
Section A requires the following information:
- Control Number, Suffix, and Account numbers
- Employee/Member’s Social Security Number
- Name and address of both the employee/member and the plan sponsor
- Contact information including telephone numbers and email addresses
- Employee/Member’s Annual Earnings
- Requested life and disability coverage details
- Signature of an Authorized Representative
Which details must be filled in by employees or members in Section B?
In Section B, the employee or member needs to provide personal details such as:
- Names of individuals requesting coverage
- Height and weight
- Health condition details, including any surgical procedures or medications
- Information regarding dependent children, if applicable
- Signature of the employee/member (and spouse if requesting their coverage)
What happens if the form is incomplete?
If the EOI form is not completed in its entirety, it will be returned unprocessed. It is essential that all sections are filled out accurately to avoid delays in coverage approval.
Why is my health history important on the EOI form?
Your health history is crucial in determining available coverage. Aetna may rely heavily on the information provided in the EOI form to assess risk and make underwriting decisions. Detailed health information can lead to potential approvals or additional assessments, such as physical exams or further medical documentation.
How is my health information protected?
Aetna takes the confidentiality of your health information seriously. The information collected in the EOI form will be treated confidentially and will not be disclosed without your authorization, except as necessary for business operations, compliance with legal obligations, or when necessary to prevent fraud.
What should I do after completing the EOI form?
After filling out the EOI form, it's advisable to make a copy for your records. Once that is done, submit the form to Aetna as instructed. Keep an eye out for any communication from Aetna regarding the status of your application.
What if my coverage is denied?
If Aetna denies coverage, they will notify you directly. This communication will generally include the reasons for denial, and you may want to inquire about potential steps for reconsideration or to address any issues found during the underwriting process.
How long does it take to process the EOI form?
The processing time for the EOI form can vary, depending on the completeness of submission and the specifics of the case. If the underwriting decision cannot be made within six months, Aetna may request that you submit a new EOI form for re-evaluation.
Common mistakes
When individuals fill out the Aetna Evidence of Insurability (EOI) form, several common mistakes can lead to processing delays or denial of coverage. Understanding these pitfalls can enhance the likelihood of successful submissions.
One frequent error is omitting essential information. The form requires completion of all items, including the Control Number, Social Security Number, and contact details. Failing to provide these details can result in the form being returned unprocessed. Ensuring that every piece of information is completed is critical.
Another significant mistake involves incorrect or incomplete names and addresses. Section A requires both the employee/member's name and your name as the plan sponsor. Inaccuracies in spelling or format may complicate communication and hinder the processing of the application.
Height and weight must be specified; otherwise, the application risks being returned. This requirement is necessary for assessing insurability and is often overlooked. Additionally, applicants sometimes forget to check the appropriate boxes regarding the requested life and disability coverage, creating further complications during the review process.
Moreover, individuals may provide vague or incomplete health information. In Section B, applicants must answer questions about their medical history. It is crucial to provide detailed information for any responses that are "Yes." Generalities can lead to complications in the underwriting process, potentially resulting in coverage denials.
The signature requirement often causes issues as well. Both the employee/member and the plan sponsor's authorized representative must sign the form. An absent signature can delay processing and affect the validity of the submission.
Forgetting to read the Privacy Notice and Misrepresentation section also constitutes a common oversight. This section offers crucial insights into how information is handled and the importance of truthfulness in disclosures. Ignoring this can lead to severe consequences, including potential fraud allegations.
Finally, neglecting to retain a copy of the completed form is a frequent mistake. Keeping a personal record is beneficial for reference as the application progresses and in case of any disputes. Understanding these typical errors can significantly improve the chances of a successful application and facilitate the approval of coverage.
Documents used along the form
The Aetna Evidence of Insurability (EOI) form is an essential document for those applying for Life and Disability insurance coverage. When completing this form, it's helpful to understand additional paperwork that may accompany it. Below are common forms and documents used with the Aetna EOI form.
- Authorization for Release of Medical Information: This form allows Aetna to gather necessary medical records from healthcare providers. It ensures that the insurance provider can assess the applicant’s health history accurately.
- Application for Life Insurance: This document collects vital information about the applicant, including personal details, desired coverage amounts, and beneficiary information. It's often a prerequisite to the EOI form.
- Health History Questionnaire: This form may require the applicant to detail medical conditions, surgeries, and medications. It assists Aetna in evaluating an applicant's risk profile for insurance coverage.
- Statement of Health: Sometimes referred to as a medical questionnaire, this form requires disclosures about any ongoing medical issues or treatments. It may help clarify any discrepancies between the EOI and the applicant's health status.
Completing these forms carefully and accurately can significantly impact the approval process for insurance coverage. Keeping thorough records can also help in any future inquiries related to your insurance application. Ensure you have all required forms completed to avoid any unnecessary delays.
Similar forms
- Insurance Application Form: Like the Aetna EOI form, an insurance application form collects essential information to determine eligibility for various types of insurance coverage. Both documents require the applicant's personal details and provide a space for health history disclosures.
- Claim Submission Form: A claim submission form, similar to the Aetna EOI form, allows individuals to provide necessary information for the processing of insurance claims. It often includes sections for personal identification and details about the claim, ensuring proper evaluation by the issuing company.
- Health Questionnaire: A health questionnaire serves a purpose akin to the Aetna EOI form by assessing an individual's health status. Both forms ask specific questions that help insurers evaluate risk and determine coverage options based on pre-existing conditions.
- Beneficiary Designation Form: Similar to the Aetna EOI form, a beneficiary designation form is used to designate individuals who will receive benefits upon the occurrence of a claim event. It often shares common elements such as collecting identifying information and signatures to ensure clarity and legal validation.
Dos and Don'ts
When filling out the Aetna Evidence of Insurability (EOI) form, there are important steps to ensure everything is completed correctly. Below are some tips on what you should do, as well as what to avoid.
- Do complete all sections in full to prevent delays in processing.
- Do provide the required control number, suffix, and account numbers in Section A.
- Do include the Employee/Member's Social Security Number accurately.
- Do verify that all names and contact information are correct and legible.
- Don't leave any required fields blank; incomplete forms will be returned.
- Don't forget to sign the form in the designated areas to validate your submission.
- Don't skip providing details about any health conditions; this information is crucial for approval.
- Don't attempt to provide false information, as this can lead to denial of coverage and legal consequences.
Misconceptions
- Misconception 1: The Aetna EOI form is optional for all members.
- Misconception 2: Only health information is necessary for the form.
- Misconception 3: Signing the form guarantees coverage.
- Misconception 4: The EOI form is only for life insurance.
- Misconception 5: Aetna does not require a copy of the EOI form.
- Misconception 6: There’s no deadline for submitting the form.
- Misconception 7: The form can be completed without consulting a representative.
- Misconception 8: All health conditions need to be disclosed in detail.
- Misconception 9: EOI forms are the same for all providers.
- Misconception 10: Once coverage is approved, there's no future obligation to update information.
Contrary to popular belief, the Evidence of Insurability (EOI) form is required for certain types of insurance coverage, particularly when applying for new or increased life insurance. It is crucial for members to understand that submitting the form is not merely a choice, but a mandated step in the application process.
While health history is a significant part, the EOI form also requires detailed personal information such as Social Security numbers, contact details, and specifics about current insurance coverage. Missing any of this information can result in the form being returned unprocessed.
Many assume that simply submitting the EOI form ensures approval of coverage. However, coverage is only effective once the form is thoroughly reviewed and approved by Aetna. A decision may take time, and Aetna may request additional details before finalizing coverage.
This form is not limited to life insurance applications. It also covers disability insurance requests, allowing members to also seek coverage for short-term or long-term disability. Both forms of coverage require substantial documentation to ensure eligibility.
Some may feel that a copy is unnecessary after submitting the form. Retaining a copy is essential, as it serves as a record of the information provided and can be instrumental in any future discussions or inquiries regarding coverage.
In fact, Aetna reserves the right to request a new EOI statement if a final underwriting decision hasn’t been made within six months. Timeliness in submitting this form is critical to avoid delays in coverage.
Completing the form without guidance can lead to errors. It is advisable for members to consult with their plan sponsor or authorized representative to ensure that all necessary sections are filled out correctly and completely.
While it’s vital to provide relevant health information, only conditions that are material to the underwriting process must be disclosed. Minor ailments may not need extensive documentation, but any severe or persistent health issues must be reported.
Insurance companies often have distinct forms and requirements. The Aetna EOI form is tailored specifically to their underwriting guidelines. Members should not assume that forms from different insurers can be used interchangeably.
Members must keep in mind that any changes in health or personal circumstances should be communicated to Aetna. Failure to update critical information could potentially result in delayed claims or coverage disputes in the future.
Key takeaways
- Complete All Sections: Ensure that every item in the form is filled out thoroughly.
- Provide Key Identifiers: Include the Control Number, Suffix, and Account numbers in Section A.
- Include Social Security Number: The Employee/Member's Social Security Number must be accurate and included in Section A.
- Confirm Contact Information: Verify that names, addresses, and all telephone numbers listed are complete.
- Cover All Coverage Requests: For life insurance, report both current and requested amounts accurately for each individual.
- Follow Dependents' Requirements: If applicable, check the appropriate boxes regarding dependent coverage in Section B.
- Health Information Matters: Answer all health questions candidly; any 'Yes' answers require further explanation.
- Authorization and Privacy: Read the Privacy Notice section to understand how your information will be used and shared.
- Submit Correctly: Submit the form only after ensuring it is complete and signed; incomplete forms will be returned, unprocessed.