A Medical History Statement is available for members and dependents who wish to obtain or enhance insurance coverage. Follow the simple steps below to apply or print a copy.

1. Select the form number button below and the form will open.
2. Complete the form for yourself online or proceed to step 3 to print a copy.
3. Print using either the print button at the end of the form or the print icon located on the Adobe toolbar.
4. Sign and date the completed form, then make a copy for your records.
5. Mail the form to the address noted at the top of page one.

If Evidence of Insurability is required for Dependents coverage, please complete online or print additional forms for each person applying. Each Medical History Statement must reflect that individual's health status. Spouse/domestic partner application must be signed by the spouse/domestic partner. Child applications should be signed by the member. Keep a copy for your records and mail the original to The Standard.

Please contact your Human Resources department with questions about coverage options, dependent eligibility and Evidence of Insurability requirements.