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*PPH1HTHSTF* Policy Number FOR OFFICE USE ONLY Health Statement Form Important Notes: 1. This form is to be accomplished by the Policy Owner/Assignee in BLOCK LETTERS. Date Received: Time Received:.

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If you or anyone in your household enrolled in a health plan through the Health Insurance Marketplace, you'll get Form 1095-A, Health Insurance Marketplace Statement. You will get this form from the Marketplace, not the IRS.

More Definitions of Proof of Good Health Proof of Good Health means an application for insurance containing health related questions and any subsequent health related test or medical report deemed relevant by the Company.

A Statement of Health is a document containing a series of questions about your overall health — such as if you're a smoker or if you've ever been treated for a medical condition, like cancer or high blood pressure.

I have examined the individual named above and to the best of my knowledge; he/she is in good physical and mental health, free of any communicable diseases and is able to function in his/her profession at full capacity. By signing below I certify that the above information is true.

I have examined the individual named above and to the best of my knowledge; he/she is in good physical and mental health, free of any communicable diseases and is able to function in his/her profession at full capacity. By signing below I certify that the above information is true.

When will a producer request that a proposed insured sign a statement of continued good health? If an applicant for life insurance does not pay an initial premium at the time of application , a statement of continued good health must be completed (along with the required premium) at the time the policy is delivered.

This form or a photographic copy of it authorizes to the extent permitted by the state laws of the applicable state any doctor or other practitioner and any hospital or sanitarium to give the Insurance Company all information you may have concerning my condition or that of my wife and children...

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232