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 Statement of Health or Evidence of Insurability form.

A Statement of Health or Evidence of Insurability form is a document containing a series of questions about the applicant's overall health and is used by the insurance company to determine if the applicant meets the company's insurability guidelines, based on their underwriting rules.

Term life insurance

You are required to complete a Statement of Health form for coverage amounts that exceed the guarantee level, late enrollments, or when adding a new spouse/partner to your coverage.

If your enrollment or increase in term life coverage requires a Statement of Health, Wells Fargo will send a request to MetLife for the coverage level you selected. The request status will be "Unprocessed" until it is sent to MetLife and "Pending" after it is sent to MetLife until MetLife approves or denies your coverage request. While it is pending you cannot make changes.

MetLife will send instructions for completing a statement of health form to your Wells Fargo email address if you have one, or by letter to your home, within 7-10 business days of either:

  • the end of your enrollment period, for elections made through Your Benefits tool; or
  • the date you made your election through Team Member Care.

After you submit the form, you can check the Statement of Health status by logging into and clicking on the “Statement of Health” link. MetLife will respond:

  • If your request is approved, you will be enrolled at the coverage level you selected, effective on the first day of the month after MetLife's approval, subject to the actively at work requirement for Optional Term Life and nonconfinement clause for Spouse/Partner Term Life. Wells Fargo will notify you and ask you to view your updated Benefits Confirmation Statement.
  • If your request is denied, you will retain your current amount or waived coverage

Optional Long-Term Disability (LTD)

During your initial enrollment period (when you first become eligible for benefits) or during Annual Benefits Enrollment, you can enroll in Optional LTD with no evidence of insurability. If you wish to enroll in Optional LTD at any other time during the year, use the form indicated in the chart below.

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.

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.