Please print clearly in blue or black ink. VOLUNTARY AND WORKSITE COVERAGE Employee Health Statement
Check one — Employer Use o New Enrollee
o Annual Enrollment
o Life Event-Type/Date
Employee Information - Failure to accurately complete the questions on this application may affect the existence or amount of coverage. Please correct any errors in the information listed below. Employee name (last, first, initial) B Employer C Buchanan Hauling & Rigging, Inc. Group policy/participant # B Account # B Cert. # B Employee SSN B Employee birthdate Multiple Answer the following questions based upon the coverage for which you are applying for you and your dependents – For CANCER, answer questions 1 and 2 only. — For CRITICAL ILLNESS and LIFE, answer questions 1 through 6. Applicant Height:_ ________ Weight:_ _________ Spouse Height:_________Weight:_ _______ YES NO 1. Have you or your dependents used tobacco in any form in the past 12 months? o o 2. In the last 10 years, have you or your dependents been diagnosed, treated, or received advice to seek treatment for any tumor, malignancy or any type of internal cancer, melanoma, leukemia, lymphoma, sarcoma or Hodgkin’s disease or been diagnosed with an elevated PSA, abnormal Pap or colposcopy? Have you had a hysterectomy or prostate removal? o o 3. In the past 5 years, have you or your dependents been hospitalized, undergone any inpatient or outpatient surgery or procedure or been advised to be hospitalized or have surgery by a physician or medical provider? o o 4. In the past 12 months, have you or your dependents been prescribed or advised to take prescription medication? o o 5. In the past 5 years, have you or your dependents ever been diagnosed, received treatment, or been advised to o o seek treatment for any mental, psychiatric, emotional or eating disorder, alcoholism, alcohol abuse, prescription or illegal drug abuse? Have you or your dependents ever been arrested for DUI, illegal drug possession or use? 6. In the past 5 years, have you or your dependents ever been diagnosed, received treatment, or been advised to seek treatment for: (circle all that apply and provide details below) diabetes, heart or vascular disease, heart attack, blood disorder, stroke, high blood pressure, asthma, emphysema or other lung disorder, kidney disease, liver disease, gallstones, pancreas disorder, colitis, Crohn’s disease, glaucoma, seizures, lupus or autoimmune disorder, multiple sclerosis, Parkinson’s, Muscular Dystrophy or any paralysis, arthritis, disorder of the back, neck, spine, or joint, including hip or knee? Have you or your dependents ever been diagnosed, treated, or advised to seek treatment for human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)? o o 7. In the past 5 years, have you or your dependents ever been diagnosed with or treated for fibromyalgia, chronic fatigue, chronic pain, carpal tunnel, muscle or nerve disorder, eye or ear disorder, vertigo, bowel or bladder disorder? o o NOTE — “Disorder” is defined as a disease, illness, injury and/or condition differing in any way from the usual or normal state or structure. Remarks — If you answered “Yes” to any medical questions above, please provide details below: Sign and date the form on back. Question No. First Name Description of illness, injury or pregnancy, medication and treatment Duration (dates) & no. of episodes Residual Effects Name and address of attending physician or hospital (including zip) o o
Union Security Insurance Company Mail to: P.O. Box 981624 El Paso, TX 79998-1624 Form 73 (04/2009)(IN)
Health 197790_219521_1_082304_00001_00001 Page 1 of 4
Made with FlippingBook - Online magazine maker