This site will guide you through the steps to complete and submit a Medical History Statement to The Standard.

Note

If a Medical History Statement is required for spouse/domestic partner, please provide them access to this site. The Medical History Statement must reflect that individual's health status and be signed by them, or by the member for a dependent child's application.

You will be asked a series of questions that will take approximately 15 minutes to answer. Your progress will be indicated at the top of each page. Your answers will be automatically transferred to the Medical History Statement form. After you answer all of the questions you will be asked to review your completed form, making changes if needed.

Before you begin, please have the following information available:

Types and amounts of coverage you are requesting
Physician names and addresses
Personal identification information (Social Security Number, Date of Birth, etc.)

For your protection, this application session will time out after 30 minutes of inactivity.

Once you have the required information, select the "Get Started" button to begin the process.

CONSENT TO ELECTRONIC TRANSACTIONS

Pursuant to the Electronic Signatures in Global and National Commerce Act, the Uniform Electronic Transaction Act and applicable state law, you consent to sending and receiving electronic records and to the use of electronic signatures. This consent applies to information, documents, forms, applications, statements, claims, or other communications made or exchanged under any plans, insurance policies or products offered or administered by The Standard.

You understand that you will need to have web browser software and Adobe® Reader® software on a computer capable of accessing the Internet and a valid email address to access and retain these electronic records. You may request a paper version of any of the electronically furnished documents at any time and The Standard will provide that document free of charge. You will inform The Standard if your email address changes or if you prefer to receive communications at a different email address. In addition, you may withdraw this consent at any time by notifying The Standard by email or at 800.843.7979 that you no longer consent to sending and receiving electronic records or to the use of electronic signatures.

By checking "I Agree" below you are consenting and agreeing to the terms and conditions set forth above.

I Agree