Individual Underwriting Questionnaire

Individual Underwriting Questionnaire
Employer Name
Name*

First NameLast Name
SSN*
DOB*

MonthDayYear
Date
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Hire:

MonthDayYear
Date
The Employee Benefit Plan is Providing Medical Coverage For:

Employee OnlyEmployee & SpouseEmployee & ChildrenFamily
The employee must answer the following health questions. Please answer them fully and truthfully. Please understand that this is not an application for health insurance for you, your spouse and/or your dependents. Your employer is applying for medical stop loss insurance to insure against excess losses incurred by its self-funded employee benefit plan (The Plan) as listed above. The only way your employer can obtain this medical stop loss insurance is you report all health information being asked for on this questionnaire. No one is authorized to change this requirement in any manner. If there are any omissions or misstatements on this questionnaire, the medical stop loss coverage may be rescinded or reimbursement claims under the policy may be denied.
1a. Is anyone named in this questionnaire currently pregnant?

YesNo
1b. Any previous high risk pregnancy?

YesNo
1c. Currently taking any medications prescribed by a physician?

YesNo
1d. Now disabled or unable to perform normal work or age-related activities?

YesNo
2.Has anyone named in this questionnaire ever been diagnosed or tested positive as having an immune system disorder, including acquired immune deficiency syndrome, AIDS), or AIDS –related complex (ARC) only if diagnosed, or HIV virus?

YesNo
3.Within the last five years, has anyone named in this questionnaire been advised or scheduled to have surgery or tests not yet completed

YesNo
4.Within the last 10 years, has anyone named in this questionnaire been seen, counseled, consulted or treated for:

Stroke, Circulatory Disorder, Heart DiseaseConnective Tissue DisorderEmphysema, Lung Disease or DisorderLiver DisorderLupusAlcohol/Drug Abuse, Mental/Nervous disorderArthritis, Back, Joint or Muscle DisorderMenstrual/Gynecological Disorder, InfertilityOrgan / Tissue Transplant (past / pending)Cancer, Tumor or Abnormal GrowthIntestinal DisorderSeizures, EpilepsyAnemia or Blood DisorderMultiple SclerosisKidney, Bladder, Prostate DisorderUncontrolled/Complication of DiabetesCongenital Abnormalities
5.Within the last five years, has anyone named in this questionnaire had any mental or physical disorders, examination, hospitalization, treatment, medical advice or surgery not mentioned above?

YesNo
PLEASE LIST MEDICATIONS AND PROVIDE FULL DETAILS TO QUESTIONS FOR WHICH YOU ANSWERED, “YES” ABOVE.
Disclosures, Authorization and Signature
I have answered the above questions to the best of my knowledge and belief. I understand and agree that no individual or group health insurance coverage will be issued to me, my spouse and/ or my dependents by Westport Insurance Corporation or Swiss Re as a result of my completion of this questionnaire. I further understand and agree that all medical coverage provided to me, my spouse and/or my dependents is or will be subject to the terms and conditions of the Employee Benefit Plan listed above.
I hereby authorize any physician, medical practitioner, hospital, clinic or other medical related facility, government agency, insurance company or other organization or person, that has any records or knowledge of me or any family member for whom coverage is provided under the aforementioned Employee Benefit Plan, to give Westport Insurance Corporation or Swiss Re or their representative(s) any such information. A photographic copy of this authorization shall be as valid as the original.
Signature

Clear
Should be Empty: