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The Aetna Evidence of Insurability (EOI) form is a crucial document for individuals seeking life and disability insurance coverage through Aetna Life Insurance Company. Its primary purpose is to collect detailed health and personal information to assess an applicant's eligibility for coverage. The form is divided into two main sections, with comprehensive instructions provided for both the employer and the employee or member. Employers must ensure accurate completion of their section, which includes important identification details, social security numbers, and coverage requests for life and disability insurance. The employee or member is responsible for filling out their section, which requires information about health conditions, hospitalizations, and medications, as well as personal identifiers such as height and weight. It is crucial that all fields are filled out completely, as any omissions could lead to delays in processing. Additionally, the form emphasizes the importance of notifying Aetna about any changes in health status between the time the form is submitted and when coverage approval is received. Overall, understanding the structure and requirements of the Aetna Evidence of Insurability form ensures that applicants can navigate the process smoothly and effectively secure the insurance coverage they need.
Aetna Evidence Of Insurability Example
Evidence of Insurability Statement
Life and Disability Coverage
Aetna Life Insurance Company
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Read This Instruction Page Carefully. |
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Aetna may contact you directly to request additional information upon receipt of this completed Statement. |
Instructions |
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Plan Sponsor |
Complete Section A in its entirety. Be sure that: |
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• All items are completed. |
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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
•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).
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Give the form to your Employee/Member for his/her confidential submission to Aetna. |
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Aetna will advise you of its coverage decision. Employee/Member will be notified directly if coverage is denied. |
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Employee/Member |
Verify that your name, address and Social Security Number as shown in Section A are complete and accurate. We may need |
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to direct additional inquiries to your attention. |
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Read the Privacy |
Complete Section B. Be sure that: |
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Notice and |
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• All items are completed. |
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Misrepresentation |
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section on |
• Only the names of individuals requesting coverage at this time are listed (B1). |
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“Page 2 of 4” of |
• Height and Weight must be provided or this form will be returned unprocessed for your completion (B1). |
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the Insurability |
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• The appropriate boxes regarding dependent child coverage are checked, if applicable (B2a, B2b, and B2c). |
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Statement before |
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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. |
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•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: |
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Approval |
Aetna Life Insurance Company |
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Fax to (Applications within the US): |
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Medical Underwriting Department |
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Fax to (International Applications Only): |
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PO Box 83641 |
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Lincoln, NE |
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If you have any questions, call us |
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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. |
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EOI |
PH Sign Req’d |
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
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.
Page 2 of 4 |
Evidence of Insurability Statement |
Make a copy for your records. |
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Mail the original to: |
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Life and Disability Coverage |
Aetna Life Insurance Company |
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Aetna Life Insurance Company |
Medical Underwriting Department |
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PO Box 83641 |
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Lincoln, NE |
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Customer Service: |
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Fax to (Applications within the US): |
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Fax to (International Applications Only): |
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A. Plan Sponsor (Employer): Complete this Section - Please print. |
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1. |
Control Number |
Suffix |
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Account |
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2. |
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Employee/Member Social Security Number |
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473705 |
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3. |
Plan Sponsor Name & Mailing Address |
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4. |
Employee/Member Name & Mailing Address |
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ATTN: |
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City |
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ZIP Code |
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ZIP Code |
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5. |
Plan Sponsor - Authorized Representative |
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7a. Employee/Member |
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8. |
Employee/Member Telephone Numbers (Including Area Code) |
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Telephone Number |
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Date of Hire (MM/DD/YYYY) |
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a. Work |
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6. |
Plan Sponsor |
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7b. Employee/Member |
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b. Home |
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Rehire Date (MM/DD/YYYY) |
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c. May we leave a message? |
Yes |
No |
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9. |
Employee/Member’s Annual Earnings |
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10. |
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Employee/Member Work |
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$ |
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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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Employee/Member |
Optional or |
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Basic Life |
Voluntary Life |
Spouse Life |
Child(ren) Life |
a.Current (Existing including Guarantee Issue) Amount of Life
Insurance Coverage? |
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$ |
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$ |
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$ |
b. Additional (New) Amount of Life Insurance Coverage requested? |
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$ |
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$ |
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$ |
c. Resulting Total Life Insurance Amount if Approved (a + b)? |
$ |
$ |
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$ |
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$ |
*Reason for Requested Coverage (indicate all that apply). |
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Annual Enrollment |
Late Applicant |
Life Event/Status Change, Reason: |
Date: |
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New Hire, Date: |
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Other (Please explain) |
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Disability Coverages (Employee/Member Only): |
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Short Term Disability: |
Current Amount $ |
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or |
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Requested Amount $ |
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or |
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% |
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Long Term Disability: |
Current Amount $ |
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or |
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Requested Amount $ |
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or |
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12. Plan Sponsor: I certify the above information is correct. |
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Plan Sponsor - Authorized Representative Signature |
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Plan Sponsor - Authorized Representative Name (Please print) |
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Date Signed (MM/DD/YYYY) |
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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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EOI |
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continued |
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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.
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Yes |
No |
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a. |
Is any individual pregnant? If Yes, Who: |
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Date Due: |
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Any pregnancy complications or problems? If Yes, explain: |
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b. |
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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c. |
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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d. |
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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e. |
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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f. |
Is any individual(s) currently taking medication(s)? If Yes, complete the following information: |
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Name of Individual |
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 provide details 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 |
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*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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No. |
Individual |
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 times)
Date
Spouse’s or Authorized Person’s Signature (Required if spouse coverage is requested)
Date
Page 4 of 4 |
File Breakdown
| Fact Name | Details |
|---|---|
| Purpose | The Aetna Evidence of Insurability (EOI) form is used to collect information to assess eligibility for life and disability coverage. |
| Required Sections | Sections A and B must be completed by the Plan Sponsor (Employer) and Employee/Member, respectively, to ensure proper processing. |
| Contact Information | The form requires both the Employee/Member’s and the Employer’s name, mailing address, and telephone numbers for verification purposes. |
| Health Information | Section B includes questions about health history and current medical conditions. These questions help assess the applicant's insurability. |
| Submission Instructions | Original forms must be mailed to Aetna's Medical Underwriting Department. It is recommended to keep a copy for personal records. |
| Timeline for Decisions | Aetna may take up to six months to make a final underwriting decision. If additional time is needed, a new EOI may be requested. |
| Privacy Notice | Aetna treats all submitted information as confidential and will not disclose it without authorization, except as allowed by law. |
| State-Specific Regulations | Residents of certain states may have varying laws that govern insurance transactions, including disclosures regarding fraud and misrepresentation. |
| Certification Requirement | Both the Employee/Member and the Plan Sponsor's authorized representative must sign the form, certifying that the information provided is true and complete. |
Guide to Using Aetna Evidence Of Insurability
After completing the Aetna Evidence of Insurability form, you'll submit it for consideration regarding your life and disability coverage. Be prepared for Aetna to reach out if any additional information is needed. Below are the steps to fill out the form properly.
- Complete Section A (Employer): Fill in all required fields.
- Provide the Control Number, Suffix, and Account numbers.
- Enter the Employee/Member’s Social Security Number.
- Fill in both the Employee/Member’s name and the Plan Sponsor's name and addresses.
- Include the phone number of your authorized representative.
- List the Employee/Member’s date of hire and their home and work telephone numbers.
- Provide both the Employee/Member's and the Plan Sponsor's email addresses.
- Fill in the Employee/Member’s annual earnings.
- Check the relevant boxes for individuals requesting Life coverage and provide coverage amounts.
- Indicate the reason for requesting coverage.
- Check the Disability coverage boxes as applicable and provide the amounts or percentages.
- Have the Authorized Representative sign the form.
- Hand the form to the Employee/Member for submission.
- Complete Section B (Employee/Member): Ensure all fields are filled out correctly.
- List only the names of individuals requesting coverage.
- Provide height and weight for each individual; this is mandatory.
- Check relevant boxes about dependent children’s coverage.
- Provide detailed answers for any medical conditions listed.
- Sign the form, and if applicable, include the spouse’s signature.
- Make a copy of the completed form for your records.
- Submit the Form: Mail the original to Aetna or fax it based on your location.
- Contact Aetna if you have any questions about the process.
Get Answers on Aetna Evidence Of Insurability
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What is the Aetna Evidence of Insurability (EOI) form used for?
The Aetna Evidence of Insurability form is a necessary document for individuals seeking life and disability insurance coverage through Aetna. It gathers essential health information to assess whether the individual qualifies for the requested insurance. The completion of this form is crucial for anyone who is applying for coverage beyond the standard limits or for additional amounts of insurance.
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Who needs to fill out the EOI form?
Both the plan sponsor (typically the employer) and the employee/member seeking coverage need to complete specific sections of the form. The plan sponsor completes Section A, while the employee/member fills out Section B. It is vital that each section is filled out accurately and completely to avoid processing delays.
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What information is required in the EOI form?
The EOI form requires various details, including:
- Control number, account numbers, and Social Security numbers.
- Names, addresses, and contact information for both the plan sponsor and the employee/member.
- Annual earnings of the employee/member.
- Current and requested amounts of insurance coverage.
- Health-related information about the employee and dependents, if applicable.
Incomplete forms may lead to delays in processing.
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How should the EOI form be submitted?
The completed EOI form should be mailed to Aetna Life Insurance Company at their Medical Underwriting Department. The address is:
Medical Underwriting Department
Aetna Life Insurance Company
PO Box 83641
Lincoln, NE 68501-3641It can also be faxed within the U.S. to 1-800-792-9710 or for international applications to 1-402-474-8426. Keep a copy for your records before submission.
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What happens after the form is submitted?
Upon receipt of the EOI form, Aetna may contact the employee/member for additional information as needed. The employee/member will be notified directly about the coverage decision. If the coverage is denied, the employee/member will receive a notification explaining the reasons for the denial.
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Is there any personal information protection provided?
Yes, Aetna treats all information provided in the EOI form as confidential. It will not disclose this information without authorization, except as necessary for conducting business, complying with laws, or preventing fraud. This ensures that your information remains protected throughout the underwriting process.
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What if the form is incomplete?
If the EOI form is not completed in full or is missing signatures, Aetna will return the form unprocessed. This can significantly delay the approval process for insurance coverage, so ensure all sections are filled out accurately before submission.
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What should I do if my health changes after submitting the form?
It is crucial to inform Aetna of any changes to your health or the information provided in your EOI form that occur between the time of submission and when you receive a coverage approval notice. Failure to do so may affect the underwriting decision and eligibility for benefits.
Common mistakes
Completing the Aetna Evidence of Insurability form requires attention to detail. Mistakes made during this process can lead to delays or even denial of coverage. Here are seven common errors to be aware of.
First, many people fail to fill out all sections of the form completely. Each section requires specific information. If you leave any items blank, your form may be returned unprocessed. Be thorough and diligent; double-check that you have answered every question. Incomplete forms will only prolong the process.
Second, providing incorrect or missing personal information is another common mistake. This includes not only your name and address but also details like your Social Security number and date of hire. Each piece of information must be accurate, as Aetna uses this data to identify your case. Missing or incorrect information could result in the form being delayed or rejected.
Third, you must ensure that any requested coverage is clearly specified. Indicate both the existing and additional coverage amounts. Many applicants overlook this step and simply list amounts without clarifying. It’s essential to outline the total requested amount clearly, including specifics about new and current coverage.
Fourth, failing to provide appropriate details about health conditions can create complications. If you check "yes" to any health-related question, you must provide clear and complete explanations. Vague responses may lead to follow-up questions, further delaying the process. Always be as specific as possible regarding any health issues.
Fifth, neglecting required signatures is a mistake that can easily complicate submissions. Both the employer and the employee need to sign the form. Ensure that you and, if relevant, your spouse sign where necessary. Missing signatures can lead to delays in processing or may invalidate the application altogether.
Sixth, some individuals underestimate the importance of keeping a copy of their completed form. Always make a copy before submission. This provides a reference point in case there are any questions or issues during processing, easing communication between you and Aetna.
Lastly, failing to note any changes in health status after submission is crucial. If your health changes after your application is submitted but before you receive coverage approval, you must inform Aetna. Not doing so could result in complications with claims or denial of coverage based on new health issues.
By avoiding these mistakes, you’ll help ensure that your Evidence of Insurability form is processed smoothly. Stay diligent and thorough in your application process for the best results.
Documents used along the form
When submitting the Aetna Evidence of Insurability form, you may also need to complete several other important documents. These additional forms ensure that your application is processed smoothly and that all necessary information is provided. Below is a list of commonly associated documents that are often needed alongside the Evidence of Insurability form.
- Health History Questionnaire: This form provides comprehensive details about your past and current health conditions. It may include questions relating to any treatments, surgeries, or chronic illnesses you have experienced. By accurately completing this questionnaire, you help ensure that the insurance company understands your overall health and can make informed decisions.
- Authorization for Release of Medical Information: This document allows insurance representatives to obtain your medical records from healthcare providers. Your authorization is essential for ensuring that all relevant health information is available for the underwriting process. It helps streamline the review of your application.
- Spousal Coverage Application: If you are applying for life insurance coverage that includes a spouse, this form is necessary. It collects information on your spouse’s health and needs. Completing this accurately ensures that both your and your spouse's insurance needs are addressed effectively.
- Supplemental Life Insurance Application: This form may be required if you're seeking additional life insurance coverage beyond what is provided in your basic plan. It will ask for specific details regarding the necessary amount of coverage and any additional beneficiaries you wish to designate. Completing this correctly helps define and secure the financial protection you want for your loved ones.
Carefully completing and submitting these forms along with your Aetna Evidence of Insurability form will help facilitate the application process, ensuring you get the coverage you need in a timely manner. Being thorough and accurate is key to avoiding delays.
Similar forms
The Aetna Evidence of Insurability form is one of several documents used to assess an individual's eligibility for insurance coverage based on their health status. Here are eight similar documents, each serving a particular function within the insurance process:
- Health Insurance Application Form: This form collects personal details and health history to determine eligibility for a health insurance policy. Like the Evidence of Insurability form, it requires honesty and completeness to avoid coverage issues.
- Life Insurance Application: This application gathers information specific to life insurance coverage, including personal data, health information, and beneficiaries. Both documents seek transparency regarding health conditions and lifestyle choices.
- Disability Insurance Application: This document is focused on assessing an applicant's ability to work and their existing health conditions. It shares similarities with the Evidence of Insurability form as both evaluate health risks associated with providing coverage.
- Pre-Existing Condition Disclosure Form: This form requires the applicant to disclose any pre-existing health conditions. It is similar to the Evidence of Insurability because both documents assess how existing health issues affect insurance coverage eligibility.
- Underwriting Questionnaire: Often used in the life insurance industry, this questionnaire dives deeper into medical history and lifestyle factors beyond the basic application. Like the Evidence of Insurability, it aims to accurately assess risk for future claims.
- Medical Questionnaire: This document typically seeks detailed medical history from an applicant, similar to the Evidence of Insurability form. It encourages openness about health conditions to ensure appropriate coverage decisions.
- Claim Form: A claim form is submitted after a medical event or loss to request benefits. It is somewhat related because the accuracy of prior disclosures on the Evidence of Insurability can impact claims processing.
- Consent for Release of Medical Information: Often required for insurance processing, this document allows insurers to obtain necessary health records. It complements the Evidence of Insurability form by ensuring that the insurer can verify the health information provided.
Each of these documents serves a crucial role in the insurance process, emphasizing the need for clear, accurate health information to ensure proper and fair coverage decisions.
Dos and Don'ts
When filling out the Aetna Evidence of Insurability form, pay attention to the following dos and don’ts to ensure a smooth process:
- Do: Complete all sections of the form thoroughly to avoid delays.
- Do: Ensure all requested identification numbers are accurately provided, including Social Security Number and Control Number.
- Do: Double-check that your name, address, and any contact information are correct and clearly printed.
- Do: Sign the form in the appropriate places and ensure that any required additional signatures are included.
- Do: Include the annual earnings of the employee/member as required.
- Don't: Leave any sections blank, as incomplete forms may be returned for correction.
- Don't: Provide false information or misrepresent any details, as this could lead to penalties.
- Don't: Forget to check all relevant boxes regarding coverage options and reasons for requesting coverage.
- Don't: Submit the form without making a copy for your records.
- Don't: Neglect to inform Aetna about any changes in health status before approval is received.
Misconceptions
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Misconception 1: The Evidence Of Insurability (EOI) form is optional.
Many individuals believe that submitting the EOI form is a choice rather than a requirement. However, if you are seeking coverage that exceeds certain limits, providing this form is essential to receive approval for additional insurance coverage.
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Misconception 2: Only health questions are relevant on the form.
While health-related questions play a crucial role, other information is equally important. Details like your height, weight, and specific dates concerning medical conditions must be included for the form to be processed. Omitting any required details can result in delays.
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Misconception 3: The employer is solely responsible for form accuracy.
Some individuals assume that the employer's role stops at providing information. In truth, it’s a shared responsibility. Employees must ensure that their own information is accurate and complete to avoid complications during the underwriting process.
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Misconception 4: Aetna does not need updates on health changes after submitting the form.
It is crucial to understand that if your health status changes after submitting the EOI form, you must inform Aetna. Changes in medical conditions can affect the outcome of your coverage application and your eligibility for insurance.
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Misconception 5: Approval is guaranteed once the EOI form is submitted.
Submitting the EOI form does not guarantee coverage approval. Aetna will review the information, and the final decision will depend on the underwriting process and their assessment of the submitted health information.
Key takeaways
Filling out the Aetna Evidence of Insurability form requires careful attention to detail. Make sure that every section, especially Section A, is fully completed by the Plan Sponsor. Incomplete forms may lead to delays in processing.
When completing Section A, the Plan Sponsor must provide essential information, such as the control number, employee’s Social Security number, and verified earnings. This information is crucial for the underwriting process.
As the Employee/Member, confirm that your personal details in Section A are accurate. This includes your name, address, and Social Security number. Any discrepancies could result in complications down the line.
For Section B, it is important to report all medical conditions truthfully. If you answer "yes" to any health-related questions, further details must be provided. Transparency is key to ensuring your coverage is not denied.
Once the form is complete, make a copy for your records before submitting it to Aetna. You can mail it or choose to fax it, depending on your preference and if you are in the U.S. or abroad.
Aetna reserves the right to request a new Evidence of Insurability Statement if a final decision cannot be made within six months. Thus, timely and accurate submission of the completed form is essential.