EAA APPLICATION FOR THE ACCIDENTAL DEATH AND DISMEMBERMENT PLAN

Here's how to purchase up to $250,000 of Accidental Death and Dismemberment Insurance
This is your application for the EAA Accidental Death & Dismemberment Plan. As a current EAA Member, you are eligible to enroll in this Plan, provided you are under age 65 (65 through 69 for those who have passed the Class III medical exam). In addition, your spouse is eligible provided he/she is under age 70. Furthermore, your unmarried, dependent children under the age of 19 (25 if they are full-time students), who reside with you and are chiefly dependent upon you for support and maintenance, are also eligible for coverage under the Family Plan when you enroll for coverage. 

  Select Your Principal Sum
$50,000
$75,000
$100,000
$150,000
$200,000
$250,000

Annual Cost

Member Plan

Full Family Plan

Under 55 55 & over Under 55 55 & over
$54.00
$81.00
$108.00
$162.00
$216.00
$270.00 		$60.00
$90.00
$120.00
$180.00
$240.00
$300.00 		$84.00
$126.00
$168.00
$252.00
$336.00
$420.00 		$96.00
$144.00
$192.00
$288.00
$384.00
$480.00
 NOTE: Premiums are based on attained age at the time of application and at the policy anniversary date. The Principal Sum applicable to the Member and Insured Dependent Spouse will reduce to 50% of the total benefit or $50,000, whichever is less, at age 65; to 25% of the total benefit or $25,000, whichever is less, at age 70. A $2 processing fee is included in all premiums. The Insurance Company reserves the right to increase premiums on a class-wide basis.

You may purchase up to $250,000 of coverage under this Plan. The premiums and coverages are shown in the Schedule. NOTE: The special aviation coverages are limited to the first $100,000 of coverage. Please consult the Plan description or call the Plan Administrator if you have any questions about this limitation. Complete the Enrollment Form below and return it along with a check for your first premium to:

Harvey W. Watt & Co., Administrator
EAA GROUP INSURANCE PLANS
P.O. Box 20787, Atlanta Airport
Atlanta, Georgia 30320