VOLUNTARY GROUP LIFE
ENROLLMENT FORM
PART IA — PLEASE PRINT IN BLACK INK— ALL APPLICANTS MUST COMPLETE BOTH SIDES OF THIS FORM
EMPLOYEE NAME (Last, First, Middle Initial)
I MALE
SPOUSE NAME (Last, First, Middle Initial)
I MALE
I FEMALE
I FEMALE
HOME MAILING ADDRESS
HOME MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
HOME PHONE NUMBER
WORK PHONE NUMBER
SOCIAL SECURITY NUMBER
HOME PHONE NUMBER
WORK PHONE NUMBER
__ __
__ __
( )
( )
( )
( )
DATE OF BIRTH
AGE
STATE OF BIRTH
DATE OF BIRTH
AGE
STATE OF BIRTH
HEIGHT __________________
HEIGHT __________________
WEIGHT __________________
WEIGHT __________________
EMPLOYEE COMPANY/GROUP NAME
SPOUSE OCCUPATION/JOB TITLE
COLORADO SCHOOL OF MINES - 002252
EMPLOYEE OCCUPATION/JOB TITLE
EMPLOYEE HIRE DATE
NOTE: Shaded employee information in Part 1A must be
completed even if not applying for coverage.
I HOURLY
I MONTHLY
I ANNUALLY
If both you and your spouse or children are employees of the
EARNINGS $__________________________
same employer and are applying for this coverage, each of
ARE YOU NOW ACTIVELY AT WORK?
HOURS WORKED PER WEEK
you must complete a separate employee application.
I YES I NO
(Excluding Overtime)
EMPLOYEE TOTAL AMOUNT APPLIED FOR: $______________
SPOUSE TOTAL AMOUNT APPLIED FOR: $______________
This coverage is: I NEW I INCREASE I DECREASE
This coverage is: I NEW I INCREASE I DECREASE
In no case will coverage exceed the maximum coverage available
to your group.
Are you currently in Military Service? I Yes I No
Is the spouse currently enrolled for Voluntary Group Life Coverage?
I
Is the employee currently enrolled for Voluntary Group Life
Yes I No
Coverage? I Yes I No
CURRENT TOBACCO USE
I
CURRENT TOBACCO USE
I
None I Cigarettes ______ Per day I Chewing Tobacco
None I Cigarettes ______ Per day I Chewing Tobacco
I
I
Other___________________________________________________
Other__________________________________________________
If None, have you ever smoked cigarettes? I Yes I No
If None, have you ever smoked cigarettes? I Yes I No
If “Yes”, date last cigarette smoked ________________
If “Yes”, date last cigarette smoked ________________
BENEFICIARY NAME AND RELATIONSHIP ARE REQUIRED
BENEFICIARY NAME AND RELATIONSHIP ARE REQUIRED
(Instructions on the Back)
(Instructions on the Back)
PRIMARY BENEFICIARY(IES) NAME
RELATIONSHIP
PRIMARY BENEFICIARY(IES) NAME
RELATIONSHIP
SECONDARY BENEFICIARY(IES) NAME
RELATIONSHIP
SECONDARY BENEFICIARY(IES) NAME
RELATIONSHIP
PART IB — CHILDREN’S COVERAGE
Please check one:
I YES I NO
NOTE: If both employee & spouse are insured, children are considered dependents of the employee. Children may not be covered by both parents.
PLEASE SIGN BELOW & COMPLETE THE HEALTH STATEMENT ON THE BACK OF THIS FORM
EMPLOYEE
DATE
SIGNATURE
SPOUSE
DATE
SIGNATURE
It is unlawful to knowingly and intentionally provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company with regard to an application
for insurance or claim for benefits. Penalties may include imprisonment, fines, denial of insurance and civil damages.
Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado Division of Insurance within the Department of Regulatory Agencies or other appropriate State Insurance
Regulatory Agency.
HOME OFFICE USE ONLY — DO NOT WRITE BELOW THIS LINE
GROUP#
UNIT/REF EFF. DATE INIT/DATE EE-GI: I Yes $____________ I APPR $ ______________ I S I N/S I CHILD $ ______________
VGL
I No
I DECL
I EXCESS I WTHDRN BY:
DATE:
I Yes $____________
I APPR $ ______________ I S I N/S I CHILD $ ______________
SPOUSE ASSIGNED #
SPS-GI:
VGL
I No
I DECL
I EXCESS I WTHDRN BY:
DATE:
FORM NO. 96432
(REV. 1-01)
EMPLOYEE/SPOUSE – DETACH FOR YOUR FILES
Medical Information Bureau Notice
When we evaluate your request for insurance, the state of your health is extremely important to us. Therefore, you are requested
to sign the authorization on the back of this form which allows us to collect the information necessary to process your application.
Your evidence of insurability may include a paramedical examination.
Any information we obtain regarding your insurability will be treated as confidential. Anthem Life Insurance Company, or its
reinsurers, may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of
life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau
member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon
request will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question
the accuracy of the information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the
procedures set forth in the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is Post Office Box 105,
Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.
Anthem Life Insurance Company, or its reinsurers, may also release information in its file to other life insurance companies to whom
you may apply for life or health insurance, or to whom a claim for benefits may be submitted.
FORM NO. 96432
(REV. 1-01)

PART II—HEALTH STATEMENT—ALL APPLICANTS MUST COMPLETE THIS SECTION
Name and telephone number of physician or facility which has your most recent COMPLETE PHYSICAL EXAMINATION RESULTS.
EMPLOYEE’S PHYSICIAN’S NAME:
SPOUSE’S PHYSICIAN’S NAME:
TELEPHONE NUMBER:
TELEPHONE NUMBER:
( )
( )
DATE OF LAST EXAMINATION:
DATE OF LAST EXAMINATION:
IF YOU ANSWER “YES” TO ANY OF QUESTIONS 1 THROUGH 5-B BELOW, GIVE COMPLETE DETAILS IN AREA #6
EMPLOYEE SPOUSE
1. a.
Have you lost 10 or more pounds in the past twelve months? If yes, give amount and cause.
I YES I NO I YES I NO
b.
Have you had an abnormal X-ray, EKG, blood test, or other diagnostic test in the past ten years?
I YES I NO I YES I NO
c.
Have you ever been denied, postponed or rated up for Life or Disability insurance?
I YES I NO I YES I NO
2. Have you ever been diagnosed and/or treated by a member of the medical profession for, or had known indication of:
a.
Heart disorder, high blood pressure, heart murmur, stroke, or chest pain?
I YES I NO I YES I NO
b.
Diabetes, disorder of the digestive system, kidneys or bladder?
I YES I NO I YES I NO
c.
Depression, anxiety, bi-polar disorder, disease/disorder of the nervous system, convulsions,
seizures, or severe headaches?
I YES I NO I YES I NO
d.
Any chronic lung disease/disorder including asthma, emphysema and tuberculosis?
I YES I NO I YES I NO
e.
Any disorder of the breasts, reproductive organs, or venereal disease?
I YES I NO I YES I NO
f.
Arthritis, strained or injured back, or any bone, joint or muscle disorder?
I YES I NO I YES I NO
g.
Alcohol and/or Drug abuse? If yes, list drug(s):________________________________________
I YES I NO I YES I NO
h.
Cancer, tumor, leukemia, anemia, disorder of the blood or immune system?
I YES I NO I YES I NO
i.
Chronic fatigue, persistent cough, recurrent lymph node enlargement, pneumonia, prolonged
night sweats, or skin lesions?
I YES I NO I YES I NO
3. a.
Do you have any physical or mental impairments, deformities, or ill health not covered above?
I YES I NO I YES I NO
If “Yes,” explain in area 6 below.
b.
Are you receiving treatment or taking medication of any kind?
I YES I NO I YES I NO
c.
Has surgery or treatment been advised for any existing physical, mental or emotional condition?
I YES I NO I YES I NO
4. a.
Are you currently pregnant? (If “Yes,” estimated due date: ___________________)
I YES I NO I YES I NO
b.
Was your last pap smear abnormal? (If yes, give date and details below).
I YES I NO I YES I NO
5. Within the last ten years, have you been treated for or diagnosed by a member of the medical profession as having:
a.
RESIDENTS OF ALL STATES OTHER THAN NEVADA: Acquired Immune Deficiency Syndrome
(AIDS), AIDS Related Complex (ARC), or any other disorder of the immune system?
I YES I NO I YES I NO
b. RESIDENTS OF NEVADA: Any disease or disorder of the immune system?
I YES I NO I YES I NO
6. PLEASE PROVIDE BELOW THE DETAILS TO ANY “YES” QUESTIONS ABOVE. ATTACH A SEPARATE SHEET IF NECESSARY.
QUESTION
 EMPLOYEE OR
DATES
HOSPITALIZED
TREATMENT
NAME AND TELEPHONE NUMBER
NUMBER
SPOUSE
DIAGNOSIS/DESCRIPTION
LAST

NAME OF MEDICATION
OF ATTENDING PHYSICIAN
(EE) (SPS)
DIAGNOSED EPISODE YES NO
AND DOSAGE
NOTE: If you need to change any information given on this form, draw a line through the information, place the correct information below or
next to the error, and initial the change.
I HEREBY APPLY for insurance under a group policy, either issued to or in which my employer or my spouse’s employer participates, subject
to all terms, conditions, and provisions of the group master policy. By my signature below, I declare that all of the statements and answers on
this application (1) are true and complete to the best of my knowledge and belief, (2) are correctly and fully recorded, (3) shall constitute a
part of my application, and (4) shall be relied upon and form the basis for any insurance coverage. I understand that a copy of this application
form will be made available at my request.
I hereby authorize my licensed physician, medical practitioner, hospital, clinic, or other medically-related facility, insurance company, the
Medical Information Bureau, or other organization or institution that has knowledge of me or my health to furnish such information to Anthem
Life Insurance Company and its reinsurers. Anthem Life Insurance Company may obtain any confidential HIV-, communicable disease-,
alcohol or drug abuse-, or mental health diagnosis/treatment-related information which may be protected by federal or state laws or
regulations. As it pertains to alcohol and drug information, this may be revoked at any time by written notice to Anthem Life Insurance
Company. Any action taken before my written revocation is received by Anthem Life Insurance Company will not be affected. I also
acknowledge receipt of the Medical Information Bureau Notice. A photocopy of this authorization shall be as valid as the original, and shall
remain so for two and one-half years from the date below.
EMPLOYEE: I request to be insured and authorize payroll deduction for coverage for myself and/or my spouse and dependent children. I
understand that if I am not actively at work on the date coverage would otherwise become effective, no coverage will be effective until the
second day following my return to work.
SPOUSE AND CHILDREN: I understand that if my spouse or child(ren) are confined in a hospital or medical care facility on the date coverage
would otherwise become effective, no coverage will be effective until the day following discharge.
EMPLOYEE
DATE
SIGNATURE
SPOUSE
DATE
SIGNATURE
FORM NO. 96432
(REV. 1-01)
BENEFICIARY DESIGNATION
Full GIVEN NAMES and RELATIONSHIP of each beneficiary must be clearly stated. If multiple Primary and/or Secondary beneficiaries are
listed, death benefits are divided equally between all the living beneficiaries, unless otherwise stated.
PRIMARY BENEFICIARY: Person or persons to receive the Life Insurance proceeds upon death of the insured.
SECONDARY BENEFICIARY: Person or persons to receive the Life Insurance proceeds when the Primary Beneficiary(ies) dies before the
Insured.
MINOR CHILDREN AS BENEFICIARIES: Please be aware that if benefits are payable to a minor or a person of unsound mind, the Claim for
Death Benefits must be signed and submitted by the legal conservator of such person and Letters of Conservatorship issued by the court must
be furnished.
If no beneficiary is stated, benefits will be paid according to the terms of the policy.
FORM NO. 96432
(REV. 1-01)