This site will guide you through the steps to complete and submit a Medical History Statement for Short Term Disability and/or Long Term Disability coverage. This form is required for your application to obtain new or enhanced insurance coverage with The Standard.

You will be asked a series of questions that will take approximately 15 minutes to answer. Your progress will be indicated at the top of each page. Your answers will be automatically transferred to the Medical History Statement form. After you answer all of the questions you will be asked to review your completed form, making changes if needed.

Then, depending on your state of residence, you will either:

• Sign the document electronically and click the "Submit" button
• OR
• Print the form, sign and mail

Before you begin, please have the following information available as the system will time-out after 30 minutes of inactivity:

• Types of coverage you are requesting (STD and LTD or LTD Only)
• Physician names and addresses
• Personal identification information (Social Security Number, Date of Birth, etc.)
• Group name and group policy number from the drop down below.

Once you have the required information, please choose a location below, write down the location and policy number and read the Consent to Electronic Transactions and then select the "Get Started" button below to begin the process.

Select your Employer Name University of Utah Campus – Policy Number 136485 University of Utah Hospitals and Clinics – Policy Number 136592

CONSENT TO ELECTRONIC TRANSACTIONS

Pursuant to the Electronic Signatures in Global and National Commerce Act, the Uniform Electronic Transaction Act and applicable state law, you consent to sending and receiving electronic records and to the use of electronic signatures. This consent applies to information, documents, forms, applications, statements, claims, or other communications made or exchanged under any plans, insurance policies or products offered or administered by The Standard.

You understand that you will need to have web browser software and Adobe® Reader® software on a computer capable of accessing the Internet and a valid email address to access and retain these electronic records. You may request a paper version of any of the electronically furnished documents at any time and The Standard will provide that document free of charge. You will inform The Standard if your email address changes or if you prefer to receive communications at a different email address. In addition, you may withdraw this consent at any time by notifying The Standard by email or at 800.843.7979 that you no longer consent to sending and receiving electronic records or to the use of electronic signatures.

By checking "I Agree" below you are consenting and agreeing to the terms and conditions set forth above.

I Agree   Get Started