Statement of Health Forms

Also known as Evidence of Insurability

Some insurance plans are only available for "open enrollment" during your initial enrollment period or within 60 days of experiencing certain Qualified Events. However, some insurance plans allow you to request enrollment or increased coverage at any time (whether during the Annual Benefits Enrollment period or not) by completing the appropriate form below.

Note: During your initial enrollment period (when you first become eligible for benefits), use these forms if you want to request coverage that is higher than the levels you can select within the online Your Benefits tool. To do this, enroll in the highest level available online, then submit a form to request an increase in your coverage.

Submit the completed form directly to the plan’s insurance provider as instructed on the form. For details, see the applicable chapter in the Benefits Book.

Term life insurance

To request enrollment or an increase in term life insurance coverage, complete the online Statement of Health process or submit the appropriate form(s) below to Metropolitan Life (MetLife).

To request these coverage changes: Complete either version of this form:
Note:
If you choose the PDF form, you’ll need to mail it in. If you use the MetLife website, register first, then click My Forms to complete and submit the form online.
Optional Term Life
Enrollment or increased coverage for your spouse or domestic partner
MetLife Statement of Health (PDF)*

Or

Statement of Health form on the MetLife website*
Spouse/Partner Term Life
Enrollment or increased coverage for your spouse or domestic partner
MetLife Statement of Health (PDF)*

Or

Statement of Health form on the MetLife website*

Note: Your spouse or domestic partner completes the form.
Dependent Term Life
New enrollment for your children
MetLife Statement of Health (PDF)*

Or

Statement of Health form on the MetLife website*

Note: Only required for new enrollments; if you've already enrolled in Dependent Term Life coverage, it's automatically provided for all your eligible children as well as any future eligible children.

Other coverage

To request: Complete and submit this form:
Optional Long-Term Disability (LTD)
Coverage for yourself
Liberty Mutual Evidence of Insurability for Long-Term Disability (PDF)*

*Wells Fargo may or may not have a relationship with websites linked to and from Teamworks (or websites linked within the documents posted on this page) and does not provide products and services represented on those websites. Please review the applicable privacy and security policies and terms and conditions for the website you are visiting.

The information presented on this website does not contain the official plan provisions of the employee benefit plans sponsored by Wells Fargo & Company. If there is a conflict or discrepancy between the statements and information contained on this website and the official plan documents, the official plan documents will govern.