Medical History Statements are available for members who wish to obtain or enhance insurance coverage. Follow the simple steps below in order to apply.

  1. Select your state of residence from the drop-down below. Then select the language preference button and the form will open.
  2. Complete the form for yourself online.
  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 form, then make a copy for your records.
  5. Mail the completed form to Standard Insurance Company at 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.

Download Medical History Statements
Form Title State of Residence Language Preference 
 
Medical History Statement