Prudential Group Insurance Evidence of Insurability Form
This file provides the evidence of insurability form for Prudential Group Insurance offered by Walmart. The form includes sections for associate information, dependent information, and detailed medical history. Instructions for submitting the completed form via mail or fax are provided.
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How do I fill this out?
To fill out this form, start by completing the associate information section followed by the relevant dependent coverage sections. Make sure to answer all questions accurately and provide complete details where requested. Finally, sign and date the form before submitting it as instructed.
How to fill out the Prudential Group Insurance Evidence of Insurability Form?
1
Complete Sections 1, 2, 4, and 5 if providing evidence of insurability for Associate coverage only.
2
Complete Sections 1, 3, 4, and 5 if providing evidence of insurability for Dependent coverage only.
3
Complete all sections if providing evidence of insurability for both Associate and Dependent coverage.
4
Fill out the form in blue or black ink and sign and date Sections 4 and 5.
5
Mail or fax the completed form to the provided address or fax number.
Who needs the Prudential Group Insurance Evidence of Insurability Form?
1
Associates of Walmart who need to provide evidence of insurability for group insurance coverage.
2
Dependents of Walmart associates who are being added for dependent coverage.
3
Employees who were previously declined for insurance coverage and need to reapply with evidence of insurability.
4
Associates who have had a change in their health status and need to update their insurance records.
5
Employees who need to provide information for other types of insurance coverage such as life or disability.
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5
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What are the instructions for submitting this form?
To submit this form, complete all required sections and ensure all questions are answered accurately. Sign and date the form in sections 4 and 5. Mail the completed form to The Prudential Insurance Company of America, Group Medical Underwriting, P.O. Box 8796, Philadelphia, PA 19176, or fax it to 877-605-6671. If you have any questions, contact Prudential Customer Service at 877-740-2116 or email medical.uw@prudential.com. My advice would be to double-check all provided information for accuracy before submission to avoid any delays or need for resubmission.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates provided for this form for 2024 and 2025. Ensure you submit the form as soon as you are notified or as per your HR guidelines.
What is the purpose of this form?
The purpose of the Prudential Group Insurance Evidence of Insurability Form is to provide necessary information for evaluating eligibility for insurance coverage. This form is required for new applications, reapplications due to changes in health status, and whenever an update is necessary for dependent coverage. Completing this form accurately ensures proper assessment of insurance requests and helps in making informed decisions regarding coverage approval.
Tell me about this form and its components and fields line-by-line.
- 1. Associate Information: Includes associate’s first name, social security number, phone number, address, and email address.
- 2. Medical History: Contains questions related to the associate’s health, medical treatments, surgeries, disabilities, and lifestyle habits like smoking.
- 3. Dependent Information: Requires details about the associate’s dependents such as their names, social security numbers, relationships, birth details, and health status.
What happens if I fail to submit this form?
If you fail to submit this form, your request for insurance coverage may be delayed or denied. It's imperative to follow instructions and provide complete details.
- Coverage Delays: Delays in processing your insurance application due to incomplete or missing information.
- Denial of Coverage: Risk of your insurance coverage being denied if insufficient evidence of insurability is provided.
- Medical Information: Lack of essential medical information needed for the evaluation of your insurance eligibility.
How do I know when to use this form?
- 1. New Applications: For associates who are applying for insurance coverage for the first time.
- 2. Reapplications: For associates who were previously declined coverage and need to reapply.
- 3. Health Status Updates: When there are changes in the associate’s or dependent’s health status that need to be reported.
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