Return form to: Minnesota Life Insurance Company • B2-4256 • 400 Robert Street North • St. Paul, Minnesota 55101-2098
GROUP LIFE INSURANCE
EVIDENCE OF INSURABILITY
M
EMPLOYER NAME: State of Delaware
POLICY NUMBER: 50166 -
EMPLOYEE INFORMATION (Required)
CHILDREN INFORMATION
FIRST NAME
MIDDLE INITIAL
LAST NAME
FIRST NAME
MIDDLE INITIAL
LAST NAME
STREET ADDRESS
CITY
00-30273.7
DATE OF EMPLOYMENT
STATE
DATE OF BIRTH
ZIP CODE
SOCIAL SECURITY NUMBER
DEPENDENT COVERAGE
SPOUSE INFORMATION
AMOUNT OF INSURANCE REQUESTED
STREET ADDRESS
E-MAIL ADDRESS (Optional)
List names and dates of birth for your eligible children below:
CITY
STATE
GENDER
MALE
FEMALE
HEIGHT
WEIGHT
OCCUPATION
DATE OF BIRTH
ZIP CODE
SOCIAL SECURITY NUMBER
HEALTH QUESTIONS
YES NO YES NO
(1) During the past three years, have you for any reason consulted a physician(s) or other
health care provider(s) or been hospitalized?
(2) During the past ten years, have you ever had, or been treated for, any of the following:
heart, lung, kidney, liver, nervous system, or mental disorder; high blood pressure;
stroke; diabetes; cancer or tumor; drug or alcohol abuse including addiction?
(3) Have you ever been diagnosed as having Acquired Immune Deficiency Syndrome
(AIDS), or any disorder of your immune system; or had any test showing evidence of
antibodies to the AIDS virus (a positive HIV test)?
If you answer yes to any question, give particulars including dates, names and addresses of doctors or
hospitals, the reason for the visit or consultation, the diagnosis, and the treatment in the Additional Health
Information section on the second page or on a separate sheet of paper.
The answers provided on this application are representations of the person signing below. The answers given are
true and complete. It is understood that Minnesota Life Insurance Company (the Company), St. Paul, Minnesota
55101-2098 shall incur no liability because of this application unless and until it is approved by the Company and
the first premium is paid while my health and other cond