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

I Agree   Get Started