premiums payable to age 65. A 20-Payment Life policy is
paid for 20 years. A Single Premium Life policy has one
premium paid at the time of issue.
Whole life insurance has lifetime insurance protection for
the insured provided the premium is paid.
Whole life policies accumulate a cash value which is
returned to you if you surrender the policy. You may borrow
against the policy’s cash value. If you do, the policy’s net
value will be reduced proportionately.
Whole life insurance is sometimes bought as an investment.
However, very little of your premium will be returned to you
if you surrender your policy in the early years. For the
rst several years, the rate of return on the cash value is
low. You should not consider any whole life policy as an
investment unless you intend to keep it for twenty years
or longer.
APPLICATION PROCESS
ELIGIBILITY
Life insurance policies are only available to persons who
are residents of the state of Wisconsin at the time the
application is submitted. Proposed insureds must be at
least 14 days old.
All ve different policies are available to residents who are
standard risks. Residents who are substandard risks are
only eligible for an Ordinary Life policy.
Underwriting of the applications of substandard risks may
require the Fund to seek information from the Medical
Information Bureau and/or an investigative consumer
report. This information will only be obtained if necessary.
The Fund is not required to provide insurance to all
residents who apply. Consequently some substandard
risks may not be eligible for insurance from the Fund. The
Fund is required to operate in a manner consistent with
private insurers with regard to policy coverage, medical
examinations, and underwriting procedures.
State Life Insurance Fund
State of Wisconsin
Ofce of the Commissioner of Insurance
P.O. Box 7873
• Madison WI 53707-7873 • (608) 266-0107 or 1-800-562-5558
oci.wi.gov/slif.htm
HISTORY OF THE FUND
The State Life Insurance Fund (Fund) is a state-sponsored
life insurance program for the benefit of residents of
Wisconsin.
The Fund is a nonprot organization and receives no subsi-
dies from the state. It is not permitted to use commissioned
agents, does not advertise, and is exempt from federal
income tax. As a result, overhead expenses are minimal.
The Fund was established in 1911 in response to a national
scandal over the improper practices of some life insurance
companies.
According to the Insurance Commissioner at the time, the
Fund was set up “. . . to give the people of the state the
benet of the best old-line insurance on a mutual plan at
the lowest possible cost.”
Originally the maximum level of coverage available to each
policyholder was $1,000. This maximum is now $10,000.
TYPES OF LIFE INSURANCE POLICIES
The Fund pays dividends on all the life insurance it issues.
The two types are:
TERM INSURANCE
A Term to Age 65 policy is offered by the Fund. The
premiums for these policies remain the same until the policy
terminates. Term to Age 65 may be converted to any type
of whole life insurance prior to age 55. (The Fund does
not offer decreasing or annually renewable term policies.)
Term insurance provides death protection for a specic
period. Death benets are paid only if you die within that
period. People usually buy term insurance to get the most
death protection for their money.
WHOLE LIFE INSURANCE
The Fund offers four different whole life policies. An
Ordinary Life policy has premiums paid throughout the life
of the policyholder. A Life Paid Up at Age 65 policy has
OCI 42-571 (R 8/2021)
MEDICAL EXAMINATIONS
The Fund requires a medical exam for applicants who are
55 years of age or older. The Fund may request exams on
other applicants. If a medical exam is required or requested,
the applicant will be required to see a licensed physician.
The Fund will pay a set fee toward the exam cost.
LIFE INSURANCE COSTS
PREMIUM TABLES
The premiums for the standard policies offered by the
Fund are given on the following page. To determine your
premium, look at your age, sex, and the policy you wish to
buy. The rates indicate the cost per $1,000 of insurance.
Multiply this rate by the amount of insurance you are buying
to determine the actual premium you will pay. If you pay
quarterly or semiannually, costs will be somewhat higher.
If you can afford to pay premiums annually, you can save
this cost.
WAIVER OF PREMIUM BENEFIT
Standard risks who buy life insurance through the Fund
automatically have a waiver of premium benet. This
means if total and permanent disability of the insured
occurs, premium payments are paid by the Fund and the
policy remains in force.
This benet expires when the insured reaches age 60
unless the insured is disabled.
CASH SURRENDER VALUE
The cash surrender value is the guaranteed amount of
cash available in the policy. Cash surrender values are
important to policyholders who wish to borrow money or
build an asset fund.
Cash surrender values may be borrowed. If you borrow the
cash surrender value and die, this amount will be deducted
from the benets paid. The Fund currently charges 8%
interest on outstanding loans. If you terminate the policy,
you will receive the net cash surrender value. If you would
like a printout of cash values for a desired plan, contact
the Fund.
OTHER CONSIDERATIONS
Cost is only one consideration in buying life insurance.
Consumers should also be concerned about the provisions
of the policy contract, the stability of the insurer, and the
service received.
APPLICATION INSTRUCTIONS
Instructions for completing the Fund application form are included on the form. However, ve important instructions
should be noted:
1. All questions in the application must be answered. The processing of the insurance will be delayed with incomplete
responses.
2. Enter the total annual premium on the application. For a $5,000 policy, the annual premium will be ve times the rate
per $1,000, etc. This must be entered on the application form even if you are paying quarterly or semiannually.
3. State the full name of all beneciaries. Do not list beneciaries as “my wife,” “my spouse,” or “Mrs. Brown.”
4. If the person to be covered by the insurance is under age 18, an owner must be designated.
5. Mail the application form and premium to:
State Life Insurance Fund
P.O. Box 7873
Madison, WI 53707-7873.
PRE NOTICE—DISCLOSURE OF
INFORMATION
State Life Insurance Fund
P.O. Box 7873
Madison, WI 53707-7873
(608) 266-0107 or 1-800-562-5558
Fax: (608) 264-6220
oci.wi.gov/slif.htm
We, or our reinsurers, may make a brief report to the MIB, Inc. MIB, Inc., is a not-for-prot membership organization of
insurance companies that operates an information exchange on behalf of its members. If you apply to another MIB member
company for life or health insurance coverage, or a claim for benets is submitted to such a company, MIB, upon request
will supply the company with the information in its le. At your request, MIB will arrange disclosure of any information it may
have in your le. If you question the accuracy of the information in MIB’s le, you may contact MIB and seek correction
in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The address of MIB’s information
ofce is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. The telephone number is 866-692-6901.
Information for consumers about MIB, Inc., may be obtained on its website at www.mib.com.
LIFE INSURANCE ANNUAL PREMIUMS PER $1,000
INCLUDES WAIVER OF PREMIUM BENEFIT AT APPLICABLE AGES
MALE PREMIUMS
L65 SP
OL 20P Life T65 Single
Issue Ordinary Twenty Paid Up Term to Premium
Age Life Pay Life at Age 65 Age 65 Life
0 8.26 10.68 8.39 N/A 120.67
1 8.37 10.85 8.50 N/A 123.07
2 8.47 11.03 8.62 N/A 125.65
3 8.57 11.21 8.73 N/A 128.30
4 8.67 11.39 8.84 N/A 131.00
5 8.77 11.57 8.95 N/A 133.76
6 8.89 11.79 9.10 N/A 136.78
7 9.02 12.01 9.24 N/A 139.86
8 9.15 12.22 9.39 N/A 143.01
9 9.27 12.44 9.53 N/A 146.22
10 9.39 12.67 9.67 N/A 149.48
11 9.56 12.93 9.86 N/A 153.10
12 9.72 13.20 10.05 N/A 156.77
13 9.88 13.46 10.24 N/A 160.49
14 10.03 13.71 10.42 N/A 164.22
15 10.17 13.96 10.59 7.19 167.92
16 10.35 14.24 10.81 7.26 171.95
17 10.52 14.51 11.02 7.30 175.90
18 10.70 14.78 11.24 7.34 179.74
19 10.87 15.05 11.45 7.37 183.65
20 11.04 15.32 11.67 7.40 187.63
21 11.25 15.63 11.93 7.45 191.99
22 11.46 15.94 12.20 7.50 196.44
23 11.67 16.25 12.48 7.54 200.98
24 11.88 16.57 12.76 7.58 205.63
25 12.10 16.89 13.06 7.63 210.37
26 12.36 17.26 13.41 7.69 215.56
27 12.63 17.64 13.77 7.76 220.91
28 12.91 18.03 14.16 7.83 226.43
29 13.21 18.43 14.56 7.91 232.14
30 13.50 18.84 14.99 7.99 238.02
31 13.86 19.31 15.49 8.11 244.33
32 14.23 19.78 16.01 8.22 250.79
33 14.60 20.26 16.56 8.32 257.37
34 14.98 20.75 17.14 8.43 264.10
35 15.38 21.24 17.75 8.52 270.95
36 15.84 21.80 18.45 8.65 278.15
37 16.31 22.37 19.19 8.76 285.47
38 16.80 22.94 19.97 8.87 292.90
39 17.31 23.53 20.81 8.97 300.46
40 17.83 24.12 21.71 9.06 308.15
41 18.34 24.74 22.67 9.18 316.04
42 18.88 25.38 23.70 9.30 324.09
43 19.44 26.04 24.83 9.42 332.31
44 20.02 26.72 26.07 9.56 340.78
45 20.64 27.44 27.44 9.71 349.49
46 21.29 28.15 28.95 9.85 358.45
47 21.97 28.89 30.64 10.00 367.68
48 22.69 29.67 32.52 10.18 377.17
49 23.45 30.48 34.63 10.37 386.95
50 24.25 31.32 37.01 10.58 397.00
51 25.07 32.13 39.67 10.88 407.39
52 25.93 32.97 42.74 11.21 418.03
53 26.83 33.84 46.29 11.56 428.90
54 27.78 34.75 50.46 11.93 440.00
55 28.77 35.70 55.43 12.33 451.33
56 29.68 36.46 N/A N/A 462.98
57 30.63 37.24 N/A N/A 474.85
58 31.61 38.05 N/A N/A 486.90
59 32.64 38.90 N/A N/A 499.12
60 33.70 39.78 N/A N/A 511.49
61 35.29 41.18 N/A N/A 524.22
62 36.97 42.65 N/A N/A 537.06
63 38.75 44.21 N/A N/A 550.00
64 40.65 45.87 N/A N/A 563.01
65 42.67 47.65 N/A N/A 576.09
66 45.15 49.76 N/A N/A 589.58
67 47.83 52.06 N/A N/A 603.18
68 50.73 54.55 N/A N/A 616.88
69 53.86 57.29 N/A N/A 630.67
70 57.24 60.28 N/A N/A 644.51
71 N/A N/A N/A N/A 659.39
72 N/A N/A N/A N/A 674.26
73 N/A N/A N/A N/A 689.05
74 N/A N/A N/A N/A 703.73
75 N/A N/A N/A N/A 718.26
76 N/A N/A N/A N/A 733.92
77 N/A N/A N/A N/A 749.50
78 N/A N/A N/A N/A 765.00
79 N/A N/A N/A N/A 780.42
80 N/A N/A N/A N/A 795.73
INCLUDES WAIVER OF PREMIUM BENEFIT AT APPLICABLE AGES
FEMALE PREMIUMS
L65 SP
OL 20P Life T65 Single
Issue Ordinary Twenty Paid Up Term to Premium
Age Life Pay Life at Age 65 Age 65 Life
0 7.89 9.99 8.01 N/A 110.58
1 7.98 10.15 8.11 N/A 112.61
2 8.07 10.30 8.21 N/A 114.86
3 8.16 10.47 8.31 N/A 117.22
4 8.25 10.62 8.41 N/A 119.62
5 8.33 10.78 8.51 N/A 122.06
6 8.45 10.97 8.64 N/A 124.74
7 8.56 11.16 8.77 N/A 127.46
8 8.67 11.36 8.90 N/A 130.25
9 8.78 11.55 9.02 N/A 133.08
10 8.89 11.74 9.15 N/A 135.96
11 9.03 11.97 9.31 N/A 139.14
12 9.17 12.21 9.48 N/A 142.38
13 9.32 12.44 9.65 N/A 145.71
14 9.45 12.67 9.81 N/A 149.08
15 9.58 12.89 9.97 6.66 152.44
16 9.74 13.15 10.17 6.70 156.12
17 9.90 13.40 10.37 6.73 159.80
18 10.06 13.66 10.57 6.76 163.53
19 10.23 13.92 10.77 6.80 167.35
20 10.39 14.19 10.98 6.83 171.27
21 10.59 14.49 11.24 6.88 175.53
22 10.79 14.80 11.50 6.94 179.91
23 11.00 15.11 11.76 6.98 184.39
24 11.20 15.42 12.03 7.02 188.94
25 11.41 15.73 12.31 7.05 193.57
26 11.66 16.09 12.65 7.11 198.61
27 11.91 16.45 12.99 7.18 203.77
28 12.17 16.83 13.35 7.24 209.07
29 12.43 17.20 13.73 7.30 214.49
30 12.70 17.59 14.12 7.35 220.04
31 13.02 18.01 14.57 7.44 225.96
32 13.34 18.45 15.05 7.52 232.01
33 13.68 18.90 15.55 7.60 238.20
34 14.02 19.35 16.08 7.67 244.53
35 14.37 19.81 16.63 7.73 250.96
36 14.77 20.32 17.27 7.82 257.74
37 15.20 20.84 17.95 7.89 264.65
38 15.63 21.37 18.67 7.96 271.68
39 16.07 21.92 19.44 8.03 278.84
40 16.54 22.48 20.27 8.09 286.17
41 17.01 23.08 21.17 8.18 293.86
42 17.51 23.70 22.16 8.27 301.76
43 18.02 24.34 23.23 8.36 309.87
44 18.56 25.00 24.40 8.47 318.20
45 19.12 25.68 25.69 8.57 326.75
46 19.73 26.39 27.13 8.74 335.67
47 20.36 27.11 28.72 8.91 344.79
48 21.02 27.85 30.49 9.08 354.12
49 21.71 28.62 32.47 9.26 363.65
50 22.42 29.42 34.70 9.44 373.39
51 23.16 30.18 37.24 9.72 383.49
52 23.93 30.97 40.16 10.01 393.82
53 24.74 31.79 43.54 10.31 404.35
54 25.58 32.63 47.51 10.63 415.08
55 26.46 33.50 52.24 10.97 426.02
56 27.26 34.20 N/A N/A 437.34
57 28.09 34.91 N/A N/A 448.85
58 28.96 35.65 N/A N/A 460.56
59 29.85 36.41 N/A N/A 472.45
60 30.78 37.20 N/A N/A 484.52
61 32.09 38.35 N/A N/A 496.89
62 33.47 39.56 N/A N/A 509.41
63 34.93 40.83 N/A N/A 522.06
64 36.48 42.17 N/A N/A 534.83
65 38.11 43.60 N/A N/A 547.69
66 40.24 45.42 N/A N/A 560.88
67 42.52 47.38 N/A N/A 574.14
68 44.96 49.48 N/A N/A 587.46
69 47.58 51.76 N/A N/A 600.83
70 50.40 54.23 N/A N/A 614.23
71 N/A N/A N/A N/A 628.45
72 N/A N/A N/A N/A 642.73
73 N/A N/A N/A N/A 657.05
74 N/A N/A N/A N/A 671.40
75 N/A N/A N/A N/A 685.76
76 N/A N/A N/A N/A 701.37
77 N/A N/A N/A N/A 716.96
78 N/A N/A N/A N/A 732.51
79 N/A N/A N/A N/A 748.00
80 N/A N/A N/A N/A 763.39
1
OCI 42-511 (R 8/2021)
APPLICATION FOR INSURANCE
Ref: Ch. 607, Wis. Stat.
State of Wisconsin
Office of the Commissioner of Insurance
State Life Insurance Fund
P.O. Box 7873
Madison, WI 53707-7873
(608) 266-0107 or 1-800-562-5558
INSTRUCTIONS: Print in ink or type all information, sign form, and forward to above address. All questions must be answered. Only
Wisconsin residents are eligible to apply for this insurance. The Fund is NOT required to provide insurance to all applicants.
A. Proposed Insured Information
1. Proposed Insured’s Name First
Middle
Last
2. Resident Address
City
State
Zip Code
3. Sex
Male Female
4. Age
Date of Birth
5. State of Birth
6. Phone
7. Email
8. Social Security # of Insured
9. Occupation
10. Employer
11. Employer Address
City
State
Zip Code
12. Who will be paying for this policy? Name
Last 4 digits of SSN
Address
City
State
Zip Code
B. Ne
w Business Product and Benefit Information
1. Complete the amount of coverage and premium for the plan of
insurance you desire. Maximum coverage amount is $10,000.
Face Amount of Insurance Annual Premium
$ Ordinary Life $ Premium Amount
$ 20-Payment Life $ Premium Amount
$ Life Paid Up at Age 65 $ Premium Amount
$ Term to Age 65 $ Premium Amount
$ Single Premium Life $ Total Premium
2. How do you wish to pay premium? (Not applicable to Single Premium
Life) If amount is less than $10, you MUST pay annually.
Annually Semiannually (Annual x .51)
Quarterly (Annual x .26)
3. Amount of premium enclosed $
Premium method may be changed only on the policy anniversary
date. The Automatic Premium Loan provision is effective on all Fund
policies.
4. Dividends are to be:
Applied to reduce premium Left to accumulate interest
Paid in cash
Unless otherwise specified, dividends will be applied to reduce
the premium.
C. Owner
ship Information
A minor (under age 18) may not be the owner.
1. Will the Proposed Insured be the Sole Owner of the new policy? [ ] Yes [ ] No
If yes, proceed to Section D, Beneficiary Information.
2. Policy Owner
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Relationship to Insured
Date of Birth
Social Security # of Owner
For office use only: Cash with Application $ Date Received Policy Number
2
OCI 42-511 (R 8/2021)
3. Contingent Owner
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Relationship to Insured
Date of Birth
Social Security # of Contingent Owner
4. Ownership will pass to the Proposed Insured at:
Age 25 Other ___________
Insured will become owner at Death of all prior owners unless noted above.
D. Beneficiary Information
The beneficiary stated below will receive the policy proceeds upon the insured’s death.
1. Who do you wish to name as Primary Beneficiary?
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Relationship to Insured
Date of Birth
Social Security Number
2. If the Primary Beneficiary does not survive you, who do you wish the policy proceeds payable to as Contingent Beneficiary?
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Relationship to Insured
Date of Birth
Social Security Number
Additional Beneficiary information provided on a separate page.
Unless other instructions are given, when more than one First Beneficiary or Contingent Beneficiary is named, all proceeds payable will
be shared equally by the First Beneficiary who survive you, or if none, then those Contingent Beneficiaries who survive you. Should no
Beneficiaries survive you, proceeds will be payable to the Owner’s Estate.
E. Declaration of Insurability
Yes No
1. Are you now in good health? If “No,” explain below............
2. Have you ever applied for life or health insurance which was
declined, postponed, or modified in any way? If “Yes,” give
details below................................................................
3. In the past three years have you engaged in skydiving,
parachuting, racing, underwater diving, or any hazardous
sport or hobby? ...................................................................
4. Do you use or have you used narcotics or other drugs,
including alcohol, which may be habit forming? If “Yes,”
explain.................................................................................
5. Have you received a conviction for Operating While
Intoxicated (OWI) within the last 5 years?.........................
6. Have you received 3 or more traffic violations in the last 24
months?.................................................................................
Additional Explanations provided on separate page.
Yes No
7. Do you have a family history of tuberculosis, diabetes,
cancer, high blood pressure, heart or kidney disorder,
mental illness or suicide? If “Yes,” give details below..........
8. Do you smoke cigarettes? If “Yes,” state daily usage. .........
Amount Per Day
9. Are you a pilot or crew member or do you contemplate
participation in aviation other than as a fare-paying
passenger? ..........................................................................
10. Do you have any policies on your life in the State Life
Insurance Fund? (Policy Number ) ........
11. Will the State Life Insurance Fund coverage applied for in
this application replace any existing life insurance? If
“Yes,” list policy number and company.............................
Company Policy Number
3
OCI 42-511 (R 8/2021)
F. Declaration of Insurability– Medical
1. To the
best of your knowledge and belief, have you ever had, been treated for, or been told that you have:
Yes No
Yes No
a. Heart trouble, high blood pressure, varicose veins,
hemorrhoids, or other disorder of the circulatory system?...
b. Diabetes, goiter, or any disorder of the glands? ..................
c. Epilepsy, fainting attacks, mental disorders, or other
disorder of the brain or nervous system?.............................
d. Cancer, tumor, syphilis, or tuberculosis? .............................
e. Tested positive for HIV in an FDA-licensed test?.................
(NOTE: Disclosure of a positive test result at an
anonymous or alternate test site or home test kits is not
required.)
f. Asthma, pleurisy, or other disorder of the respiratory
system?................................................................................
g. Neck or back strain, injury, or hernia?..................................
h. Are you currently taking any type of medication? ................
i. Ulcer, disorder of stomach, intestines, liver, or gall
bladder? ...............................................................................
j. Sugar in urine, kidney trouble, or other disorder of the
genitourinary tract? ..............................................................
k. Arthritis, rheumatism, or other disorder of the bones, joints,
or muscles?..........................................................................
l. Psychiatric, psychological, alcohol, and/or drug treatment?
m. Impairment of sight, speech, hearing, or any disorder of the
eye, ear, nose, or throat? .....................................................
n. Surgical operation performed or been advised to have
performed?...........................................................................
o. Medical advice, examination, hospitalization, consultation,
or treatment during the past 5 years not previously
mentioned? ..........................................................................
Give details for each “Yes” response above:
[Attach Additional Page(s) as Needed.]
Date
Occurred
Duration
Degree of
Recovery
Physician’s Name and Address for Condition
Question No. Condition
2. Name of Present Doctor
Clinic Name
Proposed Insured’s Height
Proposed Insured’s Weight
lbs.
Street Address City State Zip Code
Weight One Year Ago
lbs.
3.
Father of Proposed Insured’s Name
Mother of Proposed Insured’s Name
Father of Proposed Insured’s Address
Mother of Proposed Insured’s Address
If Deceased, Cause of Death and Age at Death
If Deceased, Cause of Death and Age at Death
G. A
greement and Signature
PLEA
SE READ THIS STATEMENT BEFORE SIGNING
I hereby declare that all answers and statements in this application are complete and true to the best of my knowledge and belief, and I hereby agree that all
answers to such questions together with this agreement shall be attached to and form a part of my policy which is issued hereunder. FURTHER, I AGREE THAT
INSURANCE APPLIED FOR HEREIN SHALL NOT BE IN FORCE AND EFFECTIVE UNTIL THE POLICY IS ISSUED DURING MY LIFETIME. The
policy shall take effect as of the Policy Date specified by the Fund in the policy.
It is required of all insurers to consider whether the purchase of new life insurance suits the needs and means of applicants. If you are satisfied that in
consideration of your present life insurance and income the insurance for which you are applying is suitable for your needs, please read and sign the following
statement.
I HAVE CONSIDERED MY PRESENT LIFE INSURANCE COVERAGE AND MY INCOME AND FEEL THAT THE INSURANCE FOR WHICH I AM APPLYING
THROUGH THE STATE LIFE INSURANCE FUND OF THE STATE OF WISCONSIN IS SUITABLE FOR ME.
Signature of Proposed Insured Signature of Parent or Guardian (If Proposed Insured Under Age 18)
Signature of Owner (If Designated in C No. 1)
DATED AT , WISCONSIN
I understand that information obtained by this Authorization will be used by the State Life Insurance Fund of Wisconsin to
determine eligibility for insurance or eligibility for benets under an existing policy. Failure to authorize the release of this
information may result in the State Life Insurance Fund’s inability to issue or modify a life insurance contract.
I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility,
insurance or reinsuring company, MIB, Inc., organization, institution or person that has pertinent records or knowledge of
me, my spouse, or my minor or dependent children’s health and health care, to release that information to the State Life
Insurance Fund of Wisconsin or its reinsurers any and all such relevant information (including information that constitutes
protected health information as dened in the privacy regulations promulgated pursuant to the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA Privacy Regulations”), but excluding psychotherapy notes, if any, in any form,
including, but not limited to, original, electronic, or photographic copies. The information is being released in connection
with an application led with the State Life Insurance Fund by, or on behalf of, the undersigned applicant. The information
authorized for release shall not include whether the individual has obtained a test for the presence of HIV antigen or
nonantigenic products of HIV or an antibody of HIV or what the results of this test were, if obtained by an individual. I
authorize the State Life Insurance Fund or its reinsurers to make a brief report of my protected health information to MIB.
I further authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility,
insurance or reinsuring company, organization, institution that has any health records regarding me, my spouse, or my
minor or dependent children, to release any and all such information or records pertaining to drug or alcohol abuse or mental
illness diagnosis or treatment to the State Life Insurance Fund.
I understand that I may revoke this Authorization by providing advance written notice of termination to the State Life Insurance
Fund. Any information released prior to the receipt of the revocation that were made in reliance upon this Authorization
cannot be retrieved nor can persons employed by the State Life Insurance Fund be held responsible or liable for such
release when the release was performed in accordance with the Authorization of state law.
I understand that there is a potential for information disclosed pursuant to this Authorization to be redisclosed
by the State Life Insurance Fund pursuant to state law or as needed for evaluation [i.e., to my authorized
representative(s), providers, insurers, third-party administrators, or as required by law]. Since information may
need to be redisclosed, there is a chance that the information re-released by the State Life Insurance Fund might
not be protected by the HIPAA Privacy Regulations.
I acknowledge that I will receive a copy of this Authorization to Obtain Medical Information.
I AGREE that a photographic copy of this Authorization shall be as valid as the original.
I AGREE this Authorization shall be valid for two years from the date shown below.
AUTHORIZATION TO OBTAIN
MEDICAL INFORMATION
State Life Insurance Fund
P.O. Box 7873
Madison, WI 53707-7873
(608) 266-0107 or (800) 562-5558
Fax: (608) 264-6220
oci.wi.gov/Pages/Funds/SLIFOverview.aspx
OCI 42-528 (R 8/2021)
Signature of Applicant
(or parent or guardian of proposed insured)
Date of Birth
Date Signed
