Fillable Printable Life Insurance Application Form - California
Fillable Printable Life Insurance Application Form - California
Life Insurance Application Form - California
Life Insurance Application and Forms Package
IDENTITY VERIFICATION:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial
institutions to obtain, verify, and record information that identifies each person who applies for life insurance.
WHAT THIS MEANS FOR YOU:
When you apply for a policy, we will ask for your name, address, date of birth, and other information that will allow us to
identify you. We may also ask to see your driver's license or other identifying documents.
What Customers Should Know
Table of Contents and Instructions
APP-PACK-IDG-CA (08/08)
PEANUTS © United Feature Syndicate, Inc.
eF
Form Name Form Number Instructions/Notes
Application for Life Insurance
ENB-7-07-CA Application for Individual Life Insurance for all MetLife
affiliated companies.
Signatures Required
Authorization EAUTH-07 Proposed Insured’s authorization for release of
information to comply with the requirements of the
Health Insurance Portability and Accountability Act
(HIPAA).
Signatures Required
Notice and Consent for HIV-Related Testing EHIV-04 Notice and Consent Authorization form for HIV related
testing. Note: Use the applicable form for each
Proposed Insured's state of residence.
Signatures Required
Producer Identification & Certification
EPID-54-07 This is to be completed by the Producer attesting to
completion of the application and certification of
Owner identity.
Signatures Required - Producer and
Agency Management
Personal Financial Information
EFIN-05 To be completed when the amount of coverage is
$1,000,000 or over. Used to obtain information about
income and assets/liabilities of the Proposed Insured(s).
Medical Supplement EMED-48-07-CA This form is to be completed by the Proposed Insured
regarding his/her health for underwriting purposes.
Note: Completion is optional if a full Paramedical/
Medical Exam is required. Best practice is to answer all
medical questions to enable the underwriter to
promptly begin the underwriting process.
For use in the State of:
California
What Producers Should Know
Incomplete Applications may delay processing.
Complete all required sections and obtain all signatures and titles (where required).
Do not use pencil to complete this application or use “white out” to make changes. If a change is made to
an answer, the respondent must initial the change.
When a replacement is involved or if the policy state has adopted a replacement regulation, the appropriate state required
replacement form(s) must be signed and dated on, or prior to, the Application date.
The NAIC Replacement Notice (EREPLDIS-NAIC) must be completed and signed in certain states if either the Proposed
Insured or the Owner has any existing life insurance policies or annuity contracts even if they are not replacing
this coverage.
While completion of the Medical Supplement (EMED-48-07-CA) is not required if the Proposed Insured is being examined,
answering all medical questions (including the full name, address and phone number for each physician consulted) is
good field underwriting practice and will enable the underwriter to promptly begin the underwriting process.
Complete and sign the Producer Identification & Certification form.
Social Security number of the Beneficiary is an optional field. However, this information is valuable in helping us locate
Beneficiaries at time of claim.
Complete all Supplements and Questionnaires indicated by the applicant's selection in this Application, and submit them
WITH this Application.
We do not accept cash, traveler's checks, credit cards or money orders as a form of payment for variable life products.
Use 'Other' as source of funds if the contract is to be funded in full or in part with monies from a reverse mortgage or
home equity loan. If this is one of several "other" fund sources, please provide details in the Section IX - Additional
Information.
When selecting List Bill as the method of payment, you must also indicate the bill frequency by checking the appropriate
box (annual, semiannual, quarterly). In the event the frequency is monthly, please indicate that in Section IX in
this application.
For details regarding products and riders, as well as a forms inventory for the new business application process, please
review the producer tools and the product section of the Producer Portal.
Additional Insureds must complete the Additional Insureds Supplement for each life proposed for coverage.
Legend for Symbols
- For Your Information
- Refer to Supplement
- Attention
APP-PACK-IDG-CA (08/08) eF
Policy Number
Application for Life Insurance
Company (Check the appropriate ONE.)
Metropolitan Life Insurance Company General American Life Insurance Company
New England Life Insurance Company MetLife Investors USA Insurance Company
MetLife Investors Insurance Company
The Company indicated in this section is
referred to as "the Company".
For Additional Insureds please complete the Additional Insureds Supplement form.
First Name Middle Name Last Name
Permanent Address
City
State
Zip
Country of Legal Residence Date of Birth
E-Mail Address
Primary Phone Number Alternate Phone Number
Preferred
Time to Call
From
To
Sex
Place of Birth
Social Security or Tax ID Number
Earned Annual Income Net Worth
U.S. Driver's License
If not licensed, please indicate other form of ID:
Passport Government Issued Photo ID
Issuer of ID
ID Number
Issue Date (if any)
Expiration Date (if any)
Name of Employer
Employer City
State
Zip
Position/Duties
NON U.S. CITIZENS ONLY - Country of Citizenship
Green Card/Visa Type
Expiration Date
Country of Permanent Residence
ID Number Years in the U.S.
Complete ONLY if the Owner is NOT the Proposed Insured.
OWNER - TRUST / BUSINESS ENTITY - Name of Entity
Tax ID Number
Trustee / Owner State
Trust Business Entity
Charity
Qualified Pension Plan
Complete the appropriate required form(s).
OWNER - OTHER INDIVIDUAL
First Name
Middle Name
Last Name
Permanent Address
City
State
Zip
Country of Legal Residence
Citizenship
Social Security or Tax ID Number
Date of Birth
Phone Number
E-Mail Address Earned Annual Income
Net Worth
Relationship to Proposed Insured
Please indicate form of ID:
U.S. Driver's License
Passport
Government Issued Photo ID
Issuer of ID
ID Number
Issue Date (if any) Expiration Date (if any)
Check if ownership should revert to Insured upon Owner and Contingent Owner’s deaths.
ENB-7-07-CA
SECTION II - About the Owner
SECTION I - About the Proposed Insured
AM
PM
PM
AM
Female
Male
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For additional Beneficiaries, use Section IX - Additional Information.
Check here if the Owner is the Primary Beneficiary.
For Primary or Contingent Beneficiaries who are NOT the Owner, complete the table below.
Beneficiary
Type
Name (First, Middle, Last)
Date of
Birth
Relationship to
Proposed Insured
Social Security
Number
(Optional)
Percentage
of Proceeds
(if not equal)
Primary
Primary
Contingent
Primary
Contingent
Check here to include all living and future natural or adopted children of the Proposed Insured as Contingent Beneficiaries. (Name all
living children above.)
If a Custodian is acting on behalf of a minor Beneficiary listed above, please use Co-Owner/Contingent Owner and UTMA
Designations Supplement form.
Federal law states that if someone with special needs has assets over $2,000, they may lose eligibility for government benefits.
Check the desired coverage(s).
Universal Life
Variable Life
Product Name
Face Amount
*
Riders and Details
Coverage Continuation (UL only)
Disability Waiver:
Specified Premium
Monthly Deduction (VUL only)
Death Benefit Option
Definition of Life Insurance:
Guideline Premium Test
Cash Value Accumulation Test
Planned Premium
Year 1
Years 2 to
Years
to
(UL only)
Whole Life
Product Name
Face Amount
*
Riders and Details
Disability Waiver
Dividend Options:
Paid-Up Additions
Other, please specify:
Automatic Premium Loan Requested
Term Life
Product Name
Face Amount
*
Riders and Details
Disability Waiver:
Convertible
Non-Convertible
For a full list of riders and options, please consult with your Producer.
Note: Some riders may require supplement forms to be completed.
For Variable Life products, please complete the Variable Life Supplement form.
* If Face Amount is equal to or exceeds $1,000,000, please complete the Personal
Financial Information form.
ADDITIONAL OPTIONS
One Time (Single) Payment Amount
1035 Exchange Amount
Requested Policy Date
Save Age
POLICY OPTIONS
Alternate Policy: Product, Face Amount and Details
Additional Policy: Product, Face Amount and Details
Group Conversion Only
Group Conversion Alternative
}
Please complete the Group Conversion Supplement form for either choice.
ENB-7-07-CA
SECTION IV - About Proposed Coverage
SECTION III - About the Beneficiary / Beneficiaries
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Does the Proposed Insured or Owner have any existing or applied for life insurance or
annuities with this or any other company?
Proposed Insured
Yes No
Owner
Yes No
If YES, please provide details of any existing or applied for Life Insurance on the Proposed Insured only.
Company
Amount of
Insurance
Year of Issue Status
Existing Applied For
Applied ForExisting
Existing Applied For
Existing Applied For
In connection with this application, has there been, or will there be with this or any other company any: surrender
transaction; loan; withdrawal; lapse; reduction or redirection of premium/consideration; or change transaction
(except conversions) involving an annuity or other life insurance?
If YES, complete Replacement Questionnaire AND any other state required replacement forms or 1035 exchange forms.
Yes No
If Proposed Insured is financially dependent on another individual, indicate individual providing support:
Spouse
Child Parent Other
Amount of insurance on individual providing support.
Existing Insurance
Insurance Applied For
If Proposed Insured is a minor, are all siblings equally insured?
Yes No
If NO, please provide details:
PREMIUM PAYOR
Proposed Insured
Owner (If NOT the Proposed Insured.)
Other (Complete the box below.)
Other Premium Payor Name
Social Security or Tax ID Number
Relationship to Proposed Insured or Owner
Reason this Person is the Payor
Permanent Address
City
State
Zip
PAYMENT MODE
(Check the appropriate ONE.)
Billing Mode:
Annual Semi-Annual Quarterly
Monthly Draft per Debit Authorization (See next page.)
Monthly
Draft per Existing Electronic Payment Number
Special Account:
Government Allotment Salary Deduction List Bill
If Special Account, provide Employer Group Number (EGN) or List Bill Number
INITIAL PAYMENT
Method of Collection:
Amount Collected with Application
Initial Premium by Electronic Funds Transfer (Must be at least a monthly amount.)
Check (Must be at least 1/12 of an annual premium.)
SOURCE OF CURRENT AND FUTURE PAYMENTS (Check ALL that apply.)
Earned Income Savings Loans
Use of Values in another Life Insurance/Annuity Contract
Other
ENB-7-07-CA
Mutual Fund/Brokerage Account Money Market Fund
Certificate of Deposit
SECTION V - About Existing or Applied for Insurance
SECTION VI - About Payment Information
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DEBIT AUTHORIZATION
Available only if the bank account holder is the Owner and/or Proposed Insured.
All others please complete the Electronic Payment (EP) Account Agreement form.
The undersigned (“I”) hereby authorize the Company with whom I am completing this application to initiate debit entries through
Metropolitan Life Insurance Company to the deposit account designated below, at the Financial Institution named below, using the
Automated Clearing House. I authorize:
1. Monthly recurring debits; AND
2. Debits made from time to time, as I authorize.
This authorization is to remain in full force and effect until the Company has received written notification from me of its termination
at such time and in such manner as to afford the Company and the Financial Institution a reasonable opportunity to act on it.
Monthly Debit Date:
Issue Date of the Policy
Debit Date on the
of each month
Bank Account Type:
Checking Savings
Bank Routing Number
Bank Account Number
Name of Financial Institution
Note: Please attach a voided check or deposit slip to Section IX - Additional Information.
We cannot establish banking services from starter checks, cash management, brokerage, or mutual fund checks. We cannot establish
banking services from foreign banks UNLESS the check is being paid in U.S. Dollars through a U.S. correspondent bank (the U.S.
correspondent bank name must be on the check).
Use Section IX - Additional Information if necessary.
1. Within the past three years has the Proposed Insured flown in a plane other than as a passenger on a commercial
airline or does he or she have plans for such activity within the next year?
Yes
No
If YES, please complete a separate Aviation Risk Supplement form for the Proposed Insured.
2. Within the past three years has the Proposed Insured participated in or does he or she plan to participate in any
of the following?
Yes
No
Underwater sports - SCUBA diving, skin diving, or similar activities
Racing sports - motorcycle, auto, motor boat or similar activities
Sky sports - skydiving, hang gliding, parachuting, ballooning or similar activities
Rock or mountain climbing or similar activities
Bungee jumping or similar activities
If YES, please complete a separate Avocation Risk Supplement form for the Proposed Insured.
3. Has the Proposed Insured traveled or resided outside the U.S. or Canada within the past two years; or does he
or she plan to travel or reside outside the U.S or Canada within the next two years?
If YES, please provide details.
Yes
No
Past Future
Duration (weeks)
Cities and Countries Purpose
4. Has the Proposed Insured EVER used tobacco or nicotine products in any form (e.g., cigars, cigarettes, cigarillos,
pipes, chewing tobacco, nicotine patches, or nicotine gum)? If YES, please provide details.
Yes
No
Product(s)
Frequency / Amount Date Last Used
ENB-7-07-CA
SECTION VII - General Risk Questions
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5. In the past 10 years, has the Proposed Insured had a driver's license suspended or revoked, been convicted
of DUI or DWI, or in the last five years had any moving violations? If YES, please provide date(s) and violation(s).
Yes
No
6. In the past 10 years, has the Proposed Insured been convicted of or pled Guilty or No Contest to a felony?
If YES, list type of felony, state, and date of occurrence.
Yes No
7. Is the Proposed Insured actively at work performing the usual duties of his or her occupation?
If NO, please provide details.
Yes No
Check here if Proposed Insured does not have a personal physician.
Physician Name
Name of Practice or Clinic
Street Address
City
State
Zip
Phone Number
Date Last Consulted
Reason
Findings/Treatment Given/Medication Prescribed
ENB-7-07-CA
If more space is needed, attach additional sheet(s).
SECTION VIII - Personal Physician
SECTION IX - Additional Information
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Certification / Agreement / Disclosure
Was a sales illustration provided for the life insurance policy as applied for?
Yes
No
A. If Yes, please choose one of the following:
An illustration was signed and matches the policy applied for. It is included with this application.
An illustration was shown or provided but is different from the policy applied for. An illustration
conforming to the policy as issued will be provided no later than at the time of policy delivery.
The sale was made using an illustration with Accelerated Payment.
If illustration was only shown on a computer screen, check and complete the details in the box below.
An illustration was displayed on a computer screen. The displayed illustration matches the policy applied for but no printed copy
of the illustration was provided. An illustration conforming to the policy as issued will be provided no later than at the time of policy
delivery. The illustration on the screen included the following personal and policy information:
1. Gender (as illustrated)
Male
Female
Unisex
2. Age
3. Rating Class (e.g. Standard Non-smoker)
Non-smoker
Smoker
4. Product Name (e.g. GAUL)
5. Face Amount
6. Dividend Option (Whole Life only)
B. If No, please choose one of the following:
Producer certifies that a signed illustration is not required by law or the policy applied for is not illustrated in this state.
No illustration conforming to the policy as applied for was shown or provided prior to or at the time of this
application. An illustration conforming to the policy as issued will be provided no later than at the time of policy delivery.
ENB-7-07-CA
I have read this application for life insurance including any amendments and supplements and to the best of my knowledge and belief, all
statements are true and complete. I also agree that:
My statements in this application and any amendment(s), paramedical/medical exam and supplement(s) are the basis of any policy issued.
This application and any amendment(s), paramedical/medical exam, and supplement(s) to this application will be attached to and become
part of the new policy.
No information will be deemed to have been given to the Company unless it is stated in this application, paramedical/medical exam,
amendment(s), or any supplement(s).
Only the Company’s President, Vice-President or Secretary may: (a) make or change any contract of insurance; (b) make a binding promise
about insurance; or (c) change or waive any term of an application, receipt, or policy.
Except as stated in the Temporary Insurance Agreement and Receipt, no insurance will take effect until a policy is delivered to the Owner
and the full first premium due is paid. It will only take effect at the time it is delivered if: (a) the condition of health of each person to be
insured is the same as stated in the application; and (b) no person to be insured has received any medical advice or treatment from a
medical practitioner since the date of the application.
If I have requested a rider that provides an acceleration of death benefit, I have received the appropriate disclosure form.
I understand that paying my insurance premiums more frequently than annually may result in a higher yearly out-of-pocket cost or different
cash values.
If I intend to replace existing insurance or annuities, I have so indicated in the appropriate section of the application.
I have received the Company’s Privacy Notice and the Life Insurance Buyer’s Guide.
If I was required to sign a Notice and Consent for HIV Testing, I have received a copy of that Notice.
Agreement / Disclosure
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Under penalties of perjury, I, the Owner, certify that:
The number shown in this application is my correct taxpayer identification number, and I am not subject to backup withholding because:
(a) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or
dividends; or
(b) the IRS has notified me that I am not subject to backup withholding.
(If you have been notified by the IRS that you are currently subject to backup withholding because of under reporting
interest or dividends on your tax return, you must cross out and initial this item.)
I am a U.S. citizen or a U.S. resident alien for tax purposes.
(If you are not a U.S. citizen or a U.S. resident alien for tax purposes, please cross out this certification and complete
form W-8BEN).
Please note: The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
If not witnessing all signatures, witness should initial next to signature being witnessed and sign below.
Signature(s) of all Proposed Insured(s)
Date
Signed at City, State
(age 18 or over)
Please complete the Additional Insureds Supplement or Child Rider Supplement form(s) if applicable.
Signature(s) of all Owner(s) (If NOT the Proposed Insured.)
Date
Signed at City, State
(age 18 or over)
If the Owner is a firm or corporation, include Officer's title with signature.
If Co-Owner or Custodian, please complete the Co-Owner/Contingent Owner and UTMA Designations Supplement form.
Signature of Parent or Guardian
Date
Signed at City, State
(If Owner or Proposed Insured is under 18, sign here. If not sign above.)
ENB-7-07-CA
Taxpayer Identification Number Certification
Signatures
Witness to Signatures
Print Name of Producer
Licensed Producer
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Authorization
Company (Check the appropriate ONE.)
The Company indicated in this section is
referred to as "the Company".
Metropolitan Life Insurance Company
General American Life Insurance Company
New England Life Insurance Company
MetLife Investors USA Insurance Company
MetLife Investors Insurance Company
Metropolitan Tower Life Insurance Company
This form was designed to comply with the requirements of the Health Insurance Portability and Accountability
Act (HIPAA).
For underwriting and claim settlement purposes regarding
me or any child(ren) under the age of 18 named below,
I authorize:
Any medical practitioner; any medical facility; any other medical
entity; any pharmacy or pharmacy-related service organization; any
insurer; any consumer reporting agency; and the MIB Group, Inc.
(MIB) to give the Company information about me or such child(ren),
including:
- personal information and data;
- entire medical file for the last ten (10) years, including medical
information, records and data (such as: office visits; patient
treatment; hospitalization; drugs prescribed; medical test results;
information about sexually transmitted diseases and other
similar information);
- information related to alcohol and drug abuse and treatment;
- information, records and data relating to Acquired Immune
Deficiency Syndrome (AIDS) or AIDS related conditions, including
Human Immunodeficiency Virus (HIV) test results; and
- information, records and data relating to mental illness.
The Company to redisclose information received pursuant to this
Authorization as authorized by me in writing or as otherwise
permitted by applicable law.
The Company to request and obtain: consumer; investigative
consumer; or motor vehicle reports.
Any employer, business associate, financial institution, or
government agency to give the Company any information or data
that it may have about: occupations; avocations; driving record;
finances; character; reputation; and aviation activities.
I understand that:
Information, records and data that the Company receives pursuant
to this Authorization will be used and maintained by the Company
as described in the Company’s Privacy Notice, a copy of which was
given to me.
All or part of the information, records and data that the Company
receives pursuant to this Authorization may be disclosed to MIB.
Such information may also be disclosed to and used by: any reinsurer;
any Company employee; or any affiliate or independent contractor
who performs a business service for the Company on the insurance
applied for or on existing insurance with the Company. Information
may also be disclosed as otherwise required or permitted by
applicable laws.
Information related to alcohol and drug abuse that has been
disclosed to the Company may be protected by Federal
Regulations 42 CFR Part 2. This information may be redisclosed
as provided in this Authorization.
Medical information, records and data disclosed may have been
subject to federal and state laws or regulations, including federal
rules issued by Health and Human Services, 45 CFR Parts
160-164. These rules set forth standards for the use, maintenance
and disclosure of such information by health care providers and
health plans. Once disclosed to the Company, this information
may no longer be subject to those laws or regulations.
Information obtained pursuant to this Authorization about me or
such child(ren) may be used, to the extent permitted by law, to
determine the insurability of other family members.
Information relating to HIV test results will only be disclosed as
permitted by applicable law.
If underwriting determines that an investigative consumer report
is needed, I will be contacted by the consumer reporting agency
and interviewed in connection with its preparation.
I am not required by law to sign this Authorization, but if I do
not, the Company will not be able to underwrite my application
for life insurance. Health care provider(s) or health care plan(s)
asked to release information pursuant to this Authorization cannot
condition treatment or payment for treatment or other benefits on
my signing it.
This Authorization will end 24 months from the date on
this form or sooner if prescribed by law. I may revoke it
at any time by writing to the Company, Privacy Office,
PO BOX 489, Warwick, RI 02887-9954 and advising it that
I have revoked this Authorization. Any action taken
before the Company has received my revocation will
be valid.
I have a right to receive a copy of this form.
A photocopy of this form is as valid as the original form.
Print Name of Proposed Insured
First Middle Last
If Proposed Insured is under 18, the
Parent or
Guardian
is to sign on line for such child.
Signature of Proposed Insured
Date
Signed at City, State
As witness, I attest to having observed all parties sign in my presence.
Witness to Signature
Signatures
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EAUTH-07
Date of Birth
Proposed Insured:
Notice and Consent For HIV-Related Testing
Company Copy
Company (Check the appropriate ONE.)
The Company indicated in this section is
referred to as "the Insurer".
Metropolitan Life Insurance Company General American Life Insurance Company
200 Park Avenue, New York, NY 10166 13045 Tesson Ferry Road, St. Louis, MO 63128
New England Life Insurance Company
MetLife Investors USA Insurance Company
501 Boylston Street, Boston, MA 02116-3700 222 Delaware Ave., Suite 900, P.O. Box 25130, Wilmington, DE 19899
MetLife Investors Insurance Company
Metropolitan Tower Life Insurance Company
13045 Tesson Ferry Road, St. Louis, MO 63128 200 Park Avenue, New York, NY 10166
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First Name Middle Name Last Name
b. False negatives: the test may give a negative result, even though
you are infected with HIV. This happens most commonly in
recently infected persons; it takes at least four to 12 weeks for a
positive test result to develop after a person is infected.
MEANING OF POSITIVE HIV TEST RESULT
A positive HIV test result does not mean that you have AIDS but that
you are at a significantly increased risk of developing problems with
your immune system including AIDS or AIDS-related conditions.
Federal authorities consider persons who are HIV antibody/antigen-
positive to be infected with the AIDS virus and capable of infecting
others. If you test positive, you should seek a follow-up visit with
your personal physician and/or a public health clinic or an AIDS
information organization. You may want to consider further
independent testing.
SIDE EFFECTS
A positive HIV test result may cause you significant anxiety, and may
also result in uninsurability for life, health, or disability insurance
policies you may apply for now or in the future. Although prohibited
by law, discrimination in housing, employment or public
accommodations may result if your test results were to become
known to others. A negative result may create a false sense of
security.
CONFIDENTIALITY
All test results will be treated confidentially. They will be reported by
the laboratory to the Insurer. The test results may be disclosed: to
the proposed insured (unless state law requires disclosure only to a
physician; see Notification section); to the person legally authorized
to consent to the test; to a licensed physician, medical practitioner,
or other person designated by the proposed insured; if your HIV test
is other than normal, to the Medical Information Bureau (MIB), a
national insurance data bank, using a non-specific code, indicating
only an abnormal test, to assure confidentiality; for statistical
reports that do not disclose the identity of any particular proposed
insured; to employees, reinsurers, or contractors of the Insurer who
have the responsibility to make underwriting decisions on behalf of
the Insurer; and to Insurer’s legal counsel who needs such
information to represent the Insurer effectively in matters concerning
the proposed insured. Results will not otherwise be disclosed except
as allowed by law or as authorized by you. Results will not be
disclosed to your agent or broker. You may request by notice to the
Insurer the names of the specific individuals or organizations that:
will have access to your file; will receive a copy of your results; or
will keep the test information in a data bank or other file.
THE HIV VIRUS AND AIDS
To evaluate your insurability, it is requested that you provide a blood
or other bodily fluid sample for testing for the presence of HIV
antibodies or antigens, as well as for other tests
such as cholesterol,
diabetes and immune disorders. The antibody test will determine the
presence of antibodies to the human immunodeficiency virus (HIV),
the virus associated with Acquired Immunodeficiency Syndrome
(AIDS), a life-threatening disorder of the immune system. The HIV
antigen test directly identifies AIDS viral particles. These tests are not
tests for AIDS; AIDS can only be diagnosed by medical evaluation. By
signing and dating this form, you agree that testing may be
performed and that underwriting decisions will be based on the test
results. You may refuse to be tested; however, such refusal may be
used by the insurer as a reason to deny coverage.
COUNSELING/ANONYMOUS TESTING
Many public health organizations have recommended that
before submitting to an HIV test, a person seek counseling
to better understand the implications of the test. You may
wish to consider counseling, at your expense, prior to
being tested or to consult with your physician or local
health department. You may also wish to be anonymously
tested.
See reverse side for counseling information. For your information,
HIV is transmitted: by sexual contact with an infected person; from
an infected mother to her newborn infant; or by exposure to infected
blood (as in needle sharing during intravenous drug use). HIV is not
spread through casual contact, such as eating with, touching or
kissing a person infected with the virus. Persons at high risk of
contracting AIDS include: males who have had sexual contact with
another male; intravenous drug users; hemophiliacs; and sexual
contacts of any of these persons. A person may remain free of
symptoms for years after becoming infected. It is thought that
persons have a 25-50% chance of developing AIDS within 10 years
of becoming infected.
THE TEST: PURPOSE AND ACCURACY
The HIV antibody test is a medically accepted three-test series which
is extremely accurate and reliable and is performed by a licensed
laboratory. It is not error free. Possible errors include:
a. False positives: the test may give a positive result, even though
you are not infected. This happens only rarely and is more
common in persons who have not engaged in high-risk behavior.
Retesting should be done to help confirm the validity of a
positive test.
