Medical History Statement (EOI) - Online Submission (This is the preferred method of submitting your Medical History Statement to The Standard Insurance Company.)

Medical History Statement (EOI) - English (fillable & printable PDF)

Medical History Statement (EOI) - Spanish (fillable & printable PDF)

Life Insurance for You
Enrolling in some life insurance coverage levels will require you and/or your dependent(s) to complete a Medical History Statement (MHS).

Life Insurance for Spouse/Domestic Partner
For currently enrolled LAwell members, an MHS will be required to enroll in spouse/domestic partner life insurance for the first time or to increase coverage. This can be waived only if you are adding a spouse/ domestic partner within 30 calendar days of a marriage or beginning a domestic partner relationship.

Disability Insurance
In most situations, enrolling in supplemental disability coverage during Open Enrollment will require you to complete a Medical History Statement (MHS).

What is the MHS?
The MHS asks a series of questions (about five) regarding your current and past medical conditions. Once received, Standard Insurance Company will review your statement and determine if any additional information or action is required of you or your dependent(s) before an approval of coverage determination can be made