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1 forms found in the DOM

Name: memberForm —

<form name="memberForm" ng-hide="isApplicationFormFromVendorPost" novalidate="" class="ng-pristine ng-invalid ng-invalid-required">
  <div class="row">
    <div class="form-group col-lg-4 col-xs-12 col-md-4 col-sm-6" ng-class="{ 'has-error' : memberForm.ssn.$invalid &amp;&amp; memberForm.showErrors }">
      <label for="ssn">SSN:</label>
      <input type="text" name="ssn" id="ssn" class="form-control ng-pristine ng-invalid ng-invalid-required" ng-model="model.ssn" required="" ssn-validation-and-formatting="" maxlength="11">
      <span class="help-block ng-hide" ng-show="memberForm.ssn.$error.required &amp;&amp; memberForm.showErrors">This field is required</span>
      <span class="help-block ng-hide" ng-show="memberForm.$error.ssn &amp;&amp; memberForm.showErrors">Please enter a valid SSN</span>
    </div>
    <div class="form-group col-lg-4 col-xs-12 col-md-4 col-sm-6" ng-class="{ 'has-error' : memberForm.employeeId.$invalid &amp;&amp; memberForm.showErrors }">
      <label for="employeeId">Employee ID:</label>
      <input type="text" name="employeeId" id="employeeId" class="form-control ng-scope ng-pristine ng-invalid ng-invalid-required" ng-model="model.employeeId" ng-disabled="employeeIdOptOut" ng-required="!employeeIdOptOut"
        tooltip="Your Employer may have provided you with a Member Id to login. If not, please check the checkbox." tooltip-trigger="focus" tooltip-placement="bottom" required="required">
      <span class="help-block ng-hide" ng-show="memberForm.employeeId.$error.required &amp;&amp; memberForm.showErrors">This field is required</span>
      <div class="form-group form-check">
        <input type="checkbox" class="form-check-input ng-pristine ng-valid" id="employeeIdOptOut" ng-model="employeeIdOptOut">
        <label class="form-check-label" for="employeeIdOptOut">Please check if you do not have Employee ID</label>
      </div>
    </div>
    <div class="form-group col-lg-4 col-xs-12 col-md-4 col-sm-6" ng-class="{ 'has-error' : memberForm.birthDate.$invalid &amp;&amp; memberForm.showErrors }">
      <label for="birthDate">Date of Birth:</label>
      <input type="text" class="form-control ng-pristine ng-invalid ng-invalid-required" ng-model="model.birthDate" name="birthDate" required="" placeholder="MM/DD/YYYY" fp-format="date" fp-parse="date" maxlength="10">
      <span class="help-block ng-hide" ng-show="!memberForm.birthDate.$error.date &amp;&amp; memberForm.birthDate.$error.required &amp;&amp; memberForm.showErrors">This field is required</span>
      <span class="help-block ng-hide" ng-show="memberForm.birthDate.$error.date &amp;&amp; memberForm.showErrors">Please enter a date in mm/dd/yyyy format</span>
    </div>
  </div>
  <!-- ngIf: invalidMember -->
</form>

Text Content

EVIDENCE OF INSURABILITY (EOI) REQUEST

Jan 8, 2024


WELCOME


Our secure Evidence of Insurability (EOI) online application allows employees to
complete and submit their EOI application online, eliminating incomplete and
illegible submissions.


WHAT IS EVIDENCE OF INSURABILITY?

Evidence of Insurability (EOI) is an application process in which you provide
information on the condition of your health or your dependent's health in order
to get certain types of insurance coverage. EOI may be required if you apply for
an amount of Optional Life and/or Dependent Life insurance coverage higher than
the guaranteed issue amount; you are currently enrolled and want to increase
your Optional Life and/or Dependent Life insurance amount; or you decline
coverage during your initial eligibility period and then want coverage at a
later date.

The completed EOI application requires review and approval before coverage
becomes effective. After review, additional information may be needed from you
or your physician for further processing. Some coverage amounts may require a
brief exam, a blood test, urinalysis and/or EKG.


ONLINE EOI FORM SUBMISSION

Online EOI submission reduces the processing of paper applications for coverage
requests, increases accuracy and confidentiality, and speeds application
processing. Our EOI application can be fully completed online and electronically
submitted. Step by step instructions will lead you through the process, which
can take approximately 20 minutes.

In order to evaluate your application, our Medical Underwriting team relies on
the accuracy of the information you have provided. Privacy and security features
have been built into our Web site to assure protection of personal information.
Your answers to the health questions are kept strictly confidential and are not
shared with your employer.

SSN: This field is required Please enter a valid SSN
Employee ID: This field is required
Please check if you do not have Employee ID
Date of Birth: This field is required Please enter a date in mm/dd/yyyy format
Continue
 

Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St.
Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Montana is the trade
name of Dearborn Life Insurance Company, an independent licensee of the Blue
Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and
Shield Symbols are registered service marks of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.

© 2022 Dearborn Life Insurance Company. All Rights Reserved.