Welcome to Bunzl Distribution USA, LLC Electronic Evidence of Insurability System which allows you to submit your Medical History Statement electronically, directly and securely to The Standard
NOTES:
Please complete all fields to the best of your knowledge. This ensures that the information submitted is complete, allowing The Standard to begin the underwriting process immediately.
Under Member/Employee ID number, please enter the last four digits of the employee's social security number. Work phone number is not required.
The information you are submitting through this site is protected by encryption technology to ensure your confidentiality. We restrict access to information about you to those employees who need to know that information to provide products or services to you. Please read our privacy policy for more details www.standard.com/eforms/9542.pdf.
Here are some things you need to know before you begin the process to submit your Medical History Statement.
New Hires
If you are a New Hire, you may elect up to the Guaranteed Issue amount of $100,000 of employee coverage without having to submit a Medical History Statement. If you are electing more than $100,000 for yourself or electing coverage for your spouse, please click on the following link to complete the required enrollment form and return a signed copy to Pinellas County School Board's Risk Management Department. Please also continue to the next screen to submit a Medical History Statement.
If you are a New Hire, you may elect up to the Guaranteed Issue amount of $100,000 of employee coverage without having to submit a Medical History Statement. If you are electing more than $100,000 for yourself or electing coverage for your spouse, please click on the following link to complete the required enrollment form and return a signed copy to Pinellas County School Board's Risk Management Department. Please also continue to the next screen to submit a Medical History Statement.
Enrollment form (New Hires Only)
If your election for Employee Optional Life is less than $100,000 and you are not applying for Spouse life, please exit this site as no further online action is required.
Existing Employees
If you are not a New Hire and elect to increase your coverage during the Annual Enrollment period or you have recently experienced a Qualifying Event, such as marriage or birth of child, you are required to submit a Medical History Statement. Please continue to the next screen.
If you are not a New Hire and elect to increase your coverage during the Annual Enrollment period or you have recently experienced a Qualifying Event, such as marriage or birth of child, you are required to submit a Medical History Statement. Please continue to the next screen.
Detailed Instructions can be found on Pinellas County School Board's Risk Management Life Insurance page or Annual Enrollment Site.
IMPORTANT: The system will time out after 30 minutes of inactivity and you will not be able to resume your prior session.
Frequently Asked Questions
I can't remember the specific date(s) pertaining to my medical visits and/or the physician's information. How should I answer the question?
Answer to the best of your knowledge, providing as much detail as possible. We will contact you if we need more information.
What if I can't finish my form before the designated deadline?
Contact your Benefits Administrator for all information pertaining to submission deadlines.
Do I need my physician to complete this form?
No. All information can be completed by you, the applicant. If we need additional information from your physician, we will contact them directly. Please be sure to list your physician's name and address on the form where noted.
Will I be asked to have a physical?
Requests for physicals are made by the underwriting staff at The Standard. If a physical is required for your requested coverage, The Standard will notify you of the details.
How will I know the decision?
You will receive a letter notifying you of the decision. In the event of a declination, you will be told the medical reason(s) for the decision, and be advised of the reconsideration process. The medical reason(s) for the declination will not be shared with anyone but you.
When is approved coverage effective?
If you apply during annual enrollment, your coverage will take effective January 1, or when you are approved for coverage (whichever is later). Please contact Risk Management to determine the effective date of your payroll deduction.
If my application is declined, do you take my existing coverage away?
No. If some amount of coverage is already in force through a guarantee issue provision or other means, any declination decision will apply only to the portion of coverage that is actually subject to EOI.
What happens if you don't get the information you need to make a decision?
In this case, an application will be closed due to Lack of Information (LOI). You will be advised that the application is closed, but we also let you know that if the needed information is received in a reasonable timeframe, your application will be re-opened.
If additional information is requested for the medical history i.e. information from a physician or an exam, is this covered by The Standard?
The Standard will pay for medical records needed to make the medical underwriting decision.
Answer to the best of your knowledge, providing as much detail as possible. We will contact you if we need more information.
What if I can't finish my form before the designated deadline?
Contact your Benefits Administrator for all information pertaining to submission deadlines.
Do I need my physician to complete this form?
No. All information can be completed by you, the applicant. If we need additional information from your physician, we will contact them directly. Please be sure to list your physician's name and address on the form where noted.
Will I be asked to have a physical?
Requests for physicals are made by the underwriting staff at The Standard. If a physical is required for your requested coverage, The Standard will notify you of the details.
How will I know the decision?
You will receive a letter notifying you of the decision. In the event of a declination, you will be told the medical reason(s) for the decision, and be advised of the reconsideration process. The medical reason(s) for the declination will not be shared with anyone but you.
When is approved coverage effective?
If you apply during annual enrollment, your coverage will take effective January 1, or when you are approved for coverage (whichever is later). Please contact Risk Management to determine the effective date of your payroll deduction.
If my application is declined, do you take my existing coverage away?
No. If some amount of coverage is already in force through a guarantee issue provision or other means, any declination decision will apply only to the portion of coverage that is actually subject to EOI.
What happens if you don't get the information you need to make a decision?
In this case, an application will be closed due to Lack of Information (LOI). You will be advised that the application is closed, but we also let you know that if the needed information is received in a reasonable timeframe, your application will be re-opened.
If additional information is requested for the medical history i.e. information from a physician or an exam, is this covered by The Standard?
The Standard will pay for medical records needed to make the medical underwriting decision.