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NOTICE AND CONSENT FORM FOR AIDS VIRUS (HIV)
UNION SECURITY INSURANCE COMPANY
2323 Grand Boulevard
Kansas City, MO 64108
To evaluate your eligibility for insurance coverage, it is requested that you consent to be tested
to determine the presence of antibodies or antigens to the Human lmmunodeficiency Virus (HIV). By
signing and dating this form, you agree that these tests may be performed and that underwriting
decisions (for example the decision to accept or reject your application) will be based on the test results.
You may have ten (10) days to decide whether you wish to sign this form. You may refuse to be tested.
However, such refusal may be used by the insurer as a reason to deny coverage. Please see below for
additional counseling information.
INFORMATION ON HIV
HIV, the virus that causes AIDS, is transmitted from one person to another through blood,
semen, and vaginal fluids. The disease is spread primarily during anal, vaginal, or oral intercourse, the
sharing of needles and syringes used for shooting drugs, or from a mother to her unborn child. HIV is not
spread through casual contact, such as eating with or touching a person infected with the virus. There is
no medical evidence that HIV is spread by kissing.
Persons most at risk of contracting HIV are men who have sex with other men; intravenous
("IV") drug users; prostitutes (male or female); persons who have had many sexual partners since 1977;
persons who received transfusions of blood or blood products prior to March, 1985; the sexual partners
of persons in any of these groups; and infants born to infected mothers.
PRE-TEST COUNSELING CONSIDERATIONS
Many public health organizations have recommended that before taking an HIV antibody/antigen
test a person seek counseling to become fully informed about the implications of such tests. You may
wish to consider obtaining such counseling at your own expense prior to being tested. Free confidential
counseling is available in most Arizona