Note
If a Medical History Statement is required for spouse/domestic partner, please provide them access to this site. The Medical History Statement must reflect that individual's health status and be signed by them.
How to submit a Medical History Statement
This site will guide you through the steps to complete and submit a Medical History Statement. 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.
Before you begin, please have the following information available as the system will time-out after 30 minutes of inactivity:
- Types and amounts of coverage you are requesting
- Physician names and addresses
- Personal identification information (Social Security Number, Date of Birth, etc.)
- Group name (Hennepin County)
- Group policy number (643148). This number is not for HCMC employees.
Once you have the required information, select the "Get Started" button to begin the process.
Please complete this field 'I Agree'. If you do not wish to submit a Medical History Statement by electronic means, please contact your benefits administrator to obtain a paper copy.