Forms All forms are in Adobe® Acrobat® format. Click on the form you need and you should see the form appear in a new window. Print, complete and sign the form before submitting it to your employer or Boston Mutual Life Insurance Company.

EVIDENCE OF INSURABILITY These forms must be completed in full by all late enrollees and by individuals requesting amounts in excess of the group contract guarantee issue limit. The Employer/Plan Administrator should fill in the Amount(s) of Insurance being requested, the Group Policy No. and the name of the Policyholder. The Applicant should provide all other information requested. When the forms have been completed in their entirety, they should be mailed along with the enrollment form, to our Group Administration Department at the Home Office of Boston Mutual.

In addition to downloading the Evidence of Insurability form, you MUST also download the appropriate HIPAA form by selecting your appropriate state. If your state is not listed - Select standard Hipaa Form.

You also need to review and print our Notice of Information Privacy Practices for your records.

A note to the Employer regarding late enrollees: After receiving notification that an applicant has been approved, you may add the individual to your plan and begin paying premiums.

A note to the Employer regarding applicants requesting amounts above the Guarantee Issue Limit: Premiums should be remitted based on the Guarantee Issue amount until notification from our Home Office that an applicant has been approved for the additional coverage(s).

Be sure to wait for notification of the effective date before collecting or remitting any premiums for late enrollees.

IMPORTANT:

The correct Evidence of Insurability form should be selected in accordance with the State of Issue of the Group Contract. Please choose the appropriate state form from the list below.