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EMPLOYEES RETIREMENT SYSTEM OF TEXAS Texas Employees Group Benefits Program (GBP)

Texas Employees Group Benefits Program (GBP)
Evidence of Insurability (EOI) Application
Active/Retired Employees
Evidence of Insurability (EOI) may be required to 1) enroll in, 2) add dependents to, or 3) increase some
GBP insurance coverages.
Evidence of Insurability means that you must provide, at no expense to Fort Dearborn Life Insurance
Company (FDL), evidence of good health. To be considered for coverage, this EOI Application (Form No.
ERS-EOI-App-05, Stock No. 8710.558-505) must be completed in its entirety, signed, dated, and returned
to FDL. You and any dependent applying for coverage are required to answer the medical questions
(which may include providing medical records and a physical exam). The information you provide on this
EOI Application and any additional information requested and received is subject to review and approval
by FDL Medical Underwriting. Coverage will either be approved or denied based on the information
Important: Write your agency name, agency number and region number in the box in the upper right-
hand corner of this Application. If you need assistance in completing this section and you are an active
employee, contact your benefits coordinator or refer to the agency list found with the EOI form at
www.ers.state.tx.us/insurance/forms. (Click on "Use the agency list in alpha order or in numerical order"
under the Form Description column.) If you are a retiree, write ERS under Agency Name and write 0327


Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston


Collections: Biology and Medicine; Environmental Sciences and Ecology