Application Form For Long Term Disability Program For Pilots - Harvey W. Watt & Company, Atlanta, Ga

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APPLICATION FORM FOR LONG TERM
DISABILITY PROGRAM FOR PILOTS
Send Completed Form to:
Harvey W. Watt & Company
P. O. Box 20787
Atlanta, GA 30320
Fax Number: 404-761-8326
It is important that all sections of this application form be fully completed. Except as otherwise provided in this application form, you
must declare all your medical history and you may not omit any details either because you or your advisors (professional or otherwise)
think that it is irrelevant or immaterial. You should declare all conditions even though you have been declared fit. You should n ot omit
information regarding investigations where you have been told that the results are satisfactory. If you have questions, please contact
Harvey W. Watt & Company at 1-800-241-6103.
Misstatement or omission of any diagnosis, treatment, therapy, advice, consultation or positive test results
may be cause to invalidate your eligibility for coverage under the LTD Program.
P
.
LEASE PRINT ALL ANSWERS AND REMARKS CLEARLY
I – P
P
O
I
ART
ERSONAL AND
CCUPATIONAL
NFORMATION
This application for LTD coverage is a (select one):
application for late entry
application for re-entry
Section 1 – Personal Information
1. Name _______________________________________________________________________________
2. Gender: Male ( ) Female ( )
Last
First
M. I.
3. Address _______________________________________________________________________________________________________________
4. City, State, Zip
5. Home Telephone #
6. Cell Telephone #
7. Email Address:
8. Date of Birth
9. Age
10. SS #
Section 2 – Occupational Information
1. Employee #
2. Rank
3. Date Employed
4. Base
5. Date of Last Flight:
6. Flight Time (Total Hours to Date) ________________ 7. Flight Time (Last 12 Months)
8. Pilot/FAA License No.:
9. Date of Current Medical
10. Class of Medical Certificate
11. FAA Special Issuance Authorization: Yes ( ) No ( )
12. FAA Waivers or Limitations
Yes ( )
No ( )
If Yes to numbers 11 or 12, give dates and details, including follow up reporting and medication issues
13. Have you ever had your professional license or medical certificate suspended, revoked, or deemed temporarily invalid?
Yes ( )
No ( )
If Yes, give dates and details ____________________________________________________________________________________________
____________________________________________________________________________________________________________________
14. Within the past 5 years, have you made a claim for or received benefits, compensation or pension for any injury, sickness, disability or impaired
condition?
Yes ( )
No ( )
If Yes, give dates and details_____________________________________________________________________________________________
____________________________________________________________________________________________________________________
15. Has any health, disability or life Insurance Company or Underwriter (1) Declined or deferred a Proposal from you?
(2) Charged or quoted more than standard rates? (3) Cancelled or declined to renew your insurance?
Yes ( )
No ( )
If Yes, give dates and details_____________________________________________________________________________________________
____________________________________________________________________________________________________________________
Released September 4, 2012
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