Evidence of insurability forms

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• Evidence of insurability form - M5995  | PDF 563 kb

  Use this form to prove a member’s insurability under most group plans. The plan administrator, the member, and their spouse (if any) must fill it out.

• SelectPac evidence of insurability form - M6129  | PDF 566 kb

  Use this form to prove a member’s insurability under a SelectPac plan. The plan administrator, the member, and their spouse (if any) must fill it out.