Form A - Applicant Information For Comprehensive Protection Plan
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41901 Chestnut Avenue
Glenview, Illinois 60025-1604
1-800-851-2201
Form A — Applicant Information for Comprehensive Protection Plan (CPP)
Long-Term Disability Benefits
Instructions:
Please complete this form and return it to the address below:
Wespath Benefits and Investments
Attention: Disability Team
1901 Chestnut Avenue
Glenview, IL 60025-1604
Part 1 – Applicant Information
Applicant name
Participant #
Present address
Social Security #
Applicant birth date
Primary phone # (
)
Gender
Alternate phone # (
)
E-mail
Part 2 – Conference/Plan Sponsor Contact Information
Conference/Plan sponsor name
Conference/Plan sponsor contact name
Phone # (
)
Address
Part 3 – Disabling Condition
1. What is your disabling condition?
2. On or about what date did you become or do you anticipate becoming disabled and unable to perform the usual and
customary duties of a United Methodist clergyperson by reason of bodily injury, disease, or mental or emotional disease
or disorder that will presumably last for at least six continuous months, exclusive of any disability resulting from:
a) service in the armed forces of any country, b) warfare, c) intentionally self-inflicted injury, or d) participation
in any criminal or unlawful act?
3. Last day worked or anticipated last date worked:
4. Is this condition due to an injury? q Yes
q No
5. If yes, when did the injury occur?
Where did it occur?
6. What is the date of the accident or the beginning of the illness to which you attribute your present condition?
7. Do you expect to return to work? q Yes
q No
If yes, when
over
(
)
a general agency of The United Methodist Church
3103/062316
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