Complete the Physician Enrollment Form to apply for coverage for yourself, your spouse and eligible children.
If you are electing an amount of coverage for you or your spouse above the Guarantee Issue Limit of $150,000 you will need to complete a Medical History Statement.
Follow the steps below to complete a Medical History Statement.
Select your state of residence. Select the View Form button to open the form. Complete the form for yourself online.
Print using either the Print button at the end of the form or the print icon located on the Adobe toolbar.
Sign and date the form, then make a copy for your records.
Mail the completed form to the address noted at the top of the form.
If Evidence of Insurability is required for Dependents coverage, please print additional Medical History Statements. Each Medical History Statement must reflect that individual's health status and be signed by the spouse, or member, if a child is applying. Keep a copy for your records and mail the original to the address noted at the top of the form.
Please contact SMA Services, Inc., with questions about coverage options, dependent eligibility and Evidence of Insurability requirements.
