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c. Been a member of any self-help group such as Alcoholics Anonymous, Narcotics Anonymous, or an industry recovery/support group or

initiative such as HIMS?

( ) Yes

( ) No

(If Yes to any questions in 11a – 11d provide details in Remarks section)

11. Within the past 5 years, have you:

a. Been hospitalized or received outpatient care?

( ) Yes

( ) No

b. Had an EKG, treadmill, heart scan, or angiogram interpreted as abnormal or temporarily varied from normal?

( ) Yes

( ) No

c. Had a diagnostic evaluation recommended by a member of the medical profession, but not carried out

(except those tests related to Human Immunodeficiency Virus (AIDS virus)?

( ) Yes

( ) No

d. Been denied a job, military service or been discharged for medical reasons?

( ) Yes

( ) No

12. Have any of your blood relatives (grandparents, parents, siblings) been diagnosed, treated, tested positive for, or been given medical advice by a

member of the medical profession for high blood pressure, heart or vascular disease, diabetes, any hereditary or genetic disease or suffered from

migraine or other vascular-type headaches?

( ) Yes

( ) No

If Yes, provide details in the table below. If additional space is needed, provide information on a signed and dated separate sheet of paper.

Was death a result

Age of

Current Age

Age at Death

Family Member

Condition or Disease

of the Condition or

Onset

(If Living)

(If applicable)

Disease?

Yes

13. List any member of the medical profession, including physicians, FAA examiners, therapists, and chiropractors you have consulted, received advice or

treatment from within the past 5 years except those tests related to Human Immunodeficiency Virus (AIDS virus). Provide the medical professional’s

name, address, phone number and reason for consultation, advice or treatment. If additional space is needed, provide information on a separate sheet

of paper that you have signed and dated.

Name

Address

Phone Number

Reason

Remarks

14.

For any “Yes” answer, provide details in the table or the blank space below. If additional space is needed, provide information on a separate sheet of

paper that you have signed and dated.

Name of Medical Professional or

Question

Diagnosis or

Date

Medical Facility providing

Address

Phone Number

Number

Treatment

ACKNOWLEDGEMENT AND DECLARATION

No agent or medical examiner can waive the answer to any question in this application nor decide on eligibility to participate in the Plan nor waive any of the

Plan Administrative Committee’s evidence of insurability requirements nor make or change any contract. Watt and/or ExpressJet shall have no knowledge

of statements made by or to the Agent or medical examiner unless such statements are shown on the application.

I have read this application and represent to Watt, ExpressJet and the Plan Administrative Committee, that I have not withheld any information and that the

statements made on this application are true, complete and correctly recorded to the best of my/our knowledge and belief. I agree that the above answers

will become part of my application and that Watt, ExpressJet and the Plan Administrative Committee can rely on these statements. I agree that this

application and/or any medical exam, form and any supplemental application or amendment to the application will be the basis for any approval for my

participation in the Plan at any time.

Coverage will not be approved nor will a claim be paid for any person who has obtained his or her FAA Medical Certificate by fraud or

concealment, or who knowingly presents a false statement or misrepresents any material information in this application for LTD coverage.

Signature_______________________________________________________________________ Date ____________________________________

ExpressJet Airlines, Inc. and the ExpressJet Airlines, Inc. Long Term Disability Program for Pilots reserve the right to impose special conditions or to refuse

to accept a proposal for coverage under the Plan.

Released September 4, 2012

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