This site will guide you through the steps to complete and submit a Medical History Statement to The Standard. The Medical History Statement may be specific to your state of residence.

Completing the form will take approximately 15 minutes. Your progress will be indicated at the top of the page. After each set of questions, click the "continue" button. You will need to have the following information available before you begin:

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

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

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

Please contact your Agency with questions about coverage options, spouse/domestic partner eligibility and Evidence of Insurability requirements.

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