Employees must complete this form if they have requested insurance coverage for themselves and are required to show evidence of good health. For questions about how to complete this form, call the MGIS representative at 800-969-6447, ext. 175. 

PLEASE NOTE: The Employer section of the Personal Health Statement should be left blank when submitting to MGIS. MGIS will have this required information in their database.

Please see FAQs regarding “Pre-existing Conditions” before submitting your enrollment form.