Proof of Good Health Forms

Also known as Statement of Health or 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 plan's 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 have already enrolled in Dependent Term Life coverage, it is 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)
Long-Term Care Plan
Increased coverage for yourself (if you enrolled before January 1, 2016; this plan is closed to new enrollment)
CNA Group Long Term Care Long Form Application (PDF)
Long-Term Care Plan — spouse/partner
Increased coverage for your enrolled spouse or domestic partner (if enrolled before January 2016; this plan is closed to new enrollment)
CNA Group Long Term Care Long Form Application (PDF)

Note: Your enrolled spouse or domestic partner completes the form.