California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 2 - Policy Forms and Other Documents › Article 1.1 - Insurer Notice and Consent Forms; Confidentiality Requirements › Section 2218.20 - Informed Consent for Testing Genetic Characteristics and Confidentiality Agreement

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  To obtain the informed consent to test genetic characteristics of an applicant
				  for life or disability income insurance, or of the proposed insured if the
				  applicant and proposed insured are not one person, and to assure
				  confidentiality of tests of genetic characteristics, life and disability income
				  insurers must use a document, printed in at least 10-point typeface, containing
				  the languages set forth below (but not the instructions indicated in brackets
				  and bold type-face). Blanks must be filled in, as indicated in the bracketed
				  instructions, prior to delivery of the form to an applicant, or proposed
				  insured (as appropriate), for review and signature. A life or disability income
				  insurer that obtains an informed consent and confidentiality agreement with
				  respect to a test of genetic characteristics must give a copy of the signed
				  agreement to the insured.
NOTICE AND CONSENT TO TEST GENETIC
				  CHARACTERISTICS AND CONFIDENTIALITY AGREEMENT
To determine whether or not to issue a life and/or a
					 disability income insurance policy to you, and for purposes specified below, if
					 any, which are related to a determination whether or not to issue a life and/or
					 a disability income policy to you, we, [
Insert full name of
					 insurer.
], require you to undergo testing of your genetic
					 characteristics. Accordingly, we request your authorization to test you for the
					 following scientifically or medically identifiable gene(s) or chromosome(s), or
					 alteration(s) thereof, which is/are known to be a cause of, or which is/are
					 determined to be associated with a statistically increased risk of development
					 of the following disease(s) or disorder(s):
Gene/Chromosome: [
Indicate gene(s) or
					 chromosome(s).]
Disease/Disorder: [
Indicate disease(s) or
					 disorder(s)
.]
We will not obtain a test of any other genetic
					 characteristics unless, in accordance with applicable law, we obtain an
					 additional, separate written consent from you to do so. We will only test genes
					 or chromosomes, or alterations thereof, which are presently associated with
					 symptoms of the disease(s) or disorder(s) indicated above. We will, however,
					 test the gene(s) or chromosome(s), or alteration(s) thereof, indicated above,
					 which are presently associated with symptoms of the disease(s) or disorder(s)
					 indicated above, whether or not you presently have symptoms of the disease(s)
					 or disorder(s) with respect to which the test(s) will be conducted. We will pay
					 the full cost for administering the test(s) of the gene(s) and/or chromosome(s)
					 indicated above, interpreting the results of the test(s) specified above to the
					 extent we consider necessary to make our determination whether or not to issue
					 a life and/or disability income policy to you, and informing you about the
					 results and interpretation of the test(s).
The following test(s) will be performed on you:
					 [
Identify each test by name and scientific reference identifier, if
					 any
.]
[
Here, indicate what will be tested, and by whom,
					 and, in plain language, the test methodology. For example, "The X laboratory
					 will take a sample of your blood and examine it microscopically." Also provide
					 the address and telephone number of the tester.
]
Our primary purpose of the test(s) authorized by you is to
					 obtain information about: [
State the genetic characteristic(s) which will
					 be indicated by the test or tests listed above.
], in order to determine
					 whether or not to issue a life and/or disability income insurance policy to
					 you.
Other uses of the test(s) authorized, which are related to
					 making a determination whether or not to issue a life and/or disability income
					 insurance policy to you, include: [
Indicate all uses which you will make
					 of the test results, including but not limited to a decision about
					 underwriting, and the effect of the results of the test(s) on premiums
.]
					 We will not use the tests for any other purposes.
Limitations of the test(s) include:
[For each test
					 authorized, indicate the limitations of the test, including, but not limited
					 to, the relative degree of accuracy of each.
]
We will notify you promptly and in writing about the
					 results of the test(s) of your genetic characteristics. Our written notice to
					 you of those results will provide you with the interpretation of the results of
					 the test(s) of your genetic characteristics which we obtain with respect to
					 making a determination whether or not to issue a life and/or disability income
					 insurance policy to you. We recommend that you give us the name and address in
					 the space below of a physician who can explain the test results and the
					 interpretation of those results which we obtain more fully to you. If you give
					 us the name and address of such a person, we will send the test results and the
					 interpretation of those results which we obtain to that person and notify you
					 in writing that we have done so. If you do not give us the name of a physician,
					 we will send the test results and the interpretation of those results which we
					 obtain directly to you.
We will treat the fact that you were asked to be tested,
					 and whether or not you agreed to be tested, and the results and interpretation
					 of the results of your test(s) which we obtain confidentially. Only persons
					 within our company or under contract with our company who have a need to know
					 about the testing and the test results for our underwriting purposes, and
					 persons necessarily involved in administering the test and interpreting the
					 test results for us, will have access to information about our request to test
					 your genetic characteristics, whether or not you agreed to be tested for
					 genetic characteristics for us, or the results and interpretation of the
					 results of the test(s) of your genetic characteristics which we obtain. We will
					 not disclose, nor allow anyone under contract with us or in our employ to
					 disclose, information about our request to test your genetic characteristics,
					 whether or not you agreed to be tested for genetic characteristics for us, or
					 the results and interpretation of the results of the test(s) of your genetic
					 characteristics which we obtain to anyone else unless you first authorize us in
					 writing to do so, or we are compelled by law to do so.
Your signature below indicates that you have read and you
					 understand this Notice and Consent to Test Genetic Characteristics and
					 Confidentiality Agreement, and the obligations imposed on us by this document,
					 and you voluntarily agree to submit to the test(s) indicated above. Your
					 signature also indicates that you have received a copy of this document, and
					 that a photocopy of this document which reflects your signature may be used by
					 us to obtain testing of your genetic characteristics, as indicated
					 above.
This authorization to test your genetic characteristics
					 expires ninety (90) days from the date you sign it; however, you may revoke it
					 at any time. Our obligations set forth in this Notice and Consent to Test
					 Genetic Characteristics and Confidentiality Agreement, including but not
					 limited to our obligations regarding confidentiality, do not expire, nor may we
					 revoke or amend them without your prior written consent.
___________________________
___________________________
Signature of Proposed Insured
Date
___________________________
Signature of Parent or Guardian
(When required by law)
Physician to Whom Test Results May Be Sent:
Name: ____________________ Address: ____________________
					 Telephone:____________________
1. New
					 article 1.1 (section
					 2218.20) and section filed 3-5-98;
					 operative 4-4-98 (Register 98, No. 10).
Note: Authority cited: Article 2.6 of Chapter 1 of Part 2
						of Division 2 and Section
						10148,
						California Insurance Code. Reference: Article 2.6 of Chapter 1 of Part 2 of
						Division 2 and Sections
						10146-
						10149.1,
						California Insurance Code.