Application Form For Long Term Disability Program For Pilots - Harvey W. Watt & Company, Atlanta, Ga Page 2
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416. Within the past 180 days, have you been unable to perform the normal duties of a commercial pilot due to injury or sickness?
Yes ( )
No ( )
If Yes, give dates and details
_____________________________________________________________________________________________________________________
17. List the amount and name of any company you may have disability coverage under
18. Within the past 5 years, name of any other airline that you have been employed with
19. Have you ever applied for coverage under the ExpressJet Airlines, Inc. Long Term Disability Program for Pilots and been deferred or denied entry as a
participant into the Plan?
Yes ( )
No ( )
If Yes, give dates and details_____________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Remarks
20.
If additional space is needed, provide information on a separate sheet of paper that you have signed and dated.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I authorize any insurance or reinsurance company, employer, licensed medical physician, medical professional, hospital, pharm acy or pharmacy benefit
managers, records custodians, other medical or medically related facility, clearing house, consumer reporting agency, the Federal Aviation Administration
(FAA) and/or the Medical Information Bureau (MIB, Inc.) that has any record of information about me to give to Harvey W. Watt & Company (Watt) and
ExpressJet Airlines, Inc. (ExpressJet) and the ExpressJet Airlines, Inc. Long Term Disability Program for Pilots (the Plan) , its insurers, reinsurers or its
authorized representatives, information about other insurance coverage, employment, age, general character, motor vehicle records, habits, court records,
foreign travel, finances, participation in hazardous activities, pharmaceutical records, medical care or advice about any physical or mental condition,
including information about drugs and alcoholism, Human Immunodeficiency Virus (HIV) infection, Acquired Immune Deficiency Syndrome (AIDS), mental
or behavioral health or psychiatric care, required by Watt and the Plan to determine my eligibility to become a participant in the Plan.
Watt, ExpressJet and the Plan may release information obtained by this Authorization to its insurers, reinsurers, to MIB, Inc., to other insurers with whom I
have policies or to whom I may apply or submit a claim, to other persons or organizations performing business or legal services in connection with an
insurance transaction for me, or as may otherwise be lawfully required. Although federal regulations require that Watt and ExpressJet inform me of the
potential that information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected by such
regulation, I understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by
federal regulations. I understand the purpose of this Authorization is to gather information to make eligibility, insurability and risk rating determinations.
I (or my authorized representative) may obtain a copy of this Authorization on request. I understand:
(1)
This Authorization may not be altered in any way;
(2)
This Authorization will be valid for two (2) years from the date signed and a photographic copy shall be as valid as the original;
(3)
A copy of this Authorization will be provided, upon request, to me or a person authorized on my behalf.
This Authorization may be revoked; however, it may not be revoked during the Plan Administrative Committee’s evidence of insurability review
(4)
of this application or to the extent Watt, ExpressJet or the Plan has taken action in reliance on this Authorization. Notice of revocation may be
sent, in writing, to Watt at its Administrative Office address above.
Signature_______________________________________________________________________ Date ____________________________________
Released September 4, 2012
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