Evidence of Insurability

Follow these steps to complete an online Evidence of Insurability Application (EOI Application):

  • Complete the below section by entering the Group Policy Number, your Social Security Number and whether the Application is for yourself, your spouse/partner, and/or your dependent child(ren). If you do not know the Group Policy Number or whether your spouse/partner or dependent child(ren) are eligible to submit an application, ask your employer's Benefits Administrator.
  • Before you begin the EOI Application, you must first provide the insurer with your consent to receive the application and complete it electronically. Read the Consumer Electronic Consent and Disclosure (Consent) carefully before clicking "AGREE." If you do not agree to the terms of the Consent or if you do not wish to complete an EOI Application electronically, you should not click "AGREE" and you should contact your employer for information about completing a paper EOI application.
  • After you have completed the above steps, you may begin the online EOI Application. The application consists of three sections: (1) Health and Personal History Application(2) Fraud Warning and (3) Signature. Make sure you answer all questions completely and accurately. You will have an opportunity to review your responses before you sign the application.

Special instructions for paper Evidence of Insurability (EOI) Applications:

If you would like to complete a paper application, please print an application by clicking below for a list of forms. If you are unsure of which application to use, please contact your Benefits Administrator or the insurer at 1-800-247-6875.

Your application(s) will not be complete until you select the SUBMIT FOR REVIEW button on the last screen of this online application. If you are inactive or away from the computer for 10 minutes, your session will time out and you will lose previously entered data.

Group Policy Number
Social Security Number - -

Please enter your Employee Social Security Number unless you have been asked by your employer to use Employee ID.

This submission is for:
Employee (Self)  
Dependent Child(ren)
Number of Children:


Your Privacy
Privacy is very important to us. By completing and submitting this application, you have entrusted us with your personal information, which we will respect and protect. Read our full Privacy Policy.

TIP: Please complete your application for yourself, your spouse/partner and all of your children who are subject to Evidence of Insurability at the same time. If you have questions about who requires Evidence of Insurability please contact your Benefits Administrator.

Evidence of Insurability will be unavailable from 11:00 pm to 3:00 am Eastern Time for regularly scheduled maintenance.