Form A - Applicant Information For Comprehensive Protection Plan Page 2
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4Part 4 – Hospitalization
1. Are you currently hospitalized? q Yes
q No
2. If yes, please provide the following information:
Name of hospital
Date of admission
Address of hospital
Reason for admission
Part 5 – Physician Information. Please include all physicians you are treating with. Attach a separate page if needed.
1. Name of physician
Specialty
Address
Phone # (
)
Fax # (
)
2. Name of physician
Specialty
Address
Phone # (
)
Fax # (
)
3. Name of physician
Specialty
Address
Phone # (
)
Fax # (
)
Part 6 – Social Security Refund Agreement
I understand that any disability income paid to me or my dependents from Social Security is subject to offset under CPP,
per Section 5.04c(7) of the Comprehensive Protection Plan document, including, but not limited to, any retroactive
benefits received. If, at any time, I or my dependents receive Social Security benefits under the disability provisions
of the Social Security Act, I agree that I, my assignees, heirs, executors, administrators or personal representatives will
repay Wespath Benefits and Investments an amount equal to the Social Security benefits that were received.
Participant Signature
Date
Part 7 – Applicant Signature
I hereby certify that the foregoing statements, including any accompanying statements, are true, complete and accurate.
Signature
Date
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