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. The appropriate form number for your state will appear in the button to the right. Select the button to open the form.
  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 the address noted at the top of page one.

Dependents Coverage

If Evidence of Insurability is required for Dependents coverage, please print additional forms. 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 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 Form Number
Medical History Statement