IACP Application

HOW TO APPLY:

Print out application from this web site.
Determine plan and amount you wish to apply for.
Complete Entire ExpressJet. application and sign.
Complete payment authorization
- Complete and sign form.
- Write void across blank check.
Complete the statement of health and sign.
Mail all of the above to:
Harvey Watt & Co-ExpressJet Life Insurance P.O. Box 20787 Atlanta GA. 30320-9805

EXPRESSJET APPLICATION
for
PILOT OCCUPATIONAL DISABILITY INSURANCE COVERAGE

Current Annual Salary $________________________
I wish to apply for the following coverage:
LUMP SUM COVERAGE (Available Through Age 55)

Plan:
- A: Level Benefit up to age 40
- B: Level Benefit up to age 50 (check one)
Amount of Coverage: $_________________ (fill in amount) (Available in $25,000 units. Minimum amount $25,000. Maximum amount $250,000. You cannot exceed 2Ľ times your current income.)
Life Endorsement (check one)
- YES
- NO
(If yes, please indicate beneficiary in part I of this application.)

DO NOT WRITE IN THIS SPACE
COVERAGE:____________________ CERTIFICATE NO:_______________ EFFECTIVE DATE:_______________ WAITING PERIOD:_______________ BENEFIT:_______________________ ENDORSEMENT:________________	COVERAGE:____________________ CERTIFICATE NO:_______________ EFFECTIVE DATE:_______________ WAITING PERIOD:_______________ BENEFIT:_______________________ ENDORSEMENT:________________
REMARKS:

Application For Insurance As a Member of The Aviation Health Association To
GREAT SOUTHERN LIFE INSURANCE COMPANY
Lincoln Plaza 500 North Akard P0. Box 219040. Dallas, Texas 75221-9040
EXCLUSIVE AGENTS
Harvey W. Watt & Company
P.O. Box 20787 • Hartsfield International Airport Atlanta, Georgia 30320-0787 • Phone: 800-241-6103 • 404-767-7501

PART I PERSONAL INFORMATION

Plan_______________________
Name________________________________________  Birth Date__________Age_____
Address________________________________________________ Zip______________
Company_______________________ Base___________ Flight Time________ ________
                                                                                                                Total              Last 12 mos.
Date Employed______________ Date of Last Flight__________ Place of Birth__________
Employee no.___________ Pilot License No._____________ Waviers or Limitations ()yes ()no
                                                                                                            (if yes give details in remarks section) Telephone No. _______________________ Social Security No.______________________
         Captain ()        co-Pilot ()        Pilot-Engineer ()        Engineer Only ()
List other business or occupations you are engaged in_______________________________
List amount of other disability coverage & company________________________________
Name of any other airline you have been employed by_______________________________
Name of your current insurance company for accident and sickness coverage and address of their claims department:

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize my company insurance provider, any licensed physician, medical practitioner, hospital, clinic, or other medically related facility, insurance company, the Medical Information Bureau or other organization, Institution or person that has any record or knowledge of me or my health, to give the Great Southern Life Insurance company or Harvey W. Watt & Co. any such Information. A photographic copy of this authorization shall be as valid as the original.
Date____________________ Signature X_______________________________________

Life Endorsement (LUMP SUM COVERAGE ONLY)
Beneficiary's Name (print)____________________________________________________
First Middle Name Last Name
Relationship to Applicant_______Address of Beneficiary________________________
If designated beneficiary does not survive insured, payment will be made in accordance with the terms of the policy.
Date_________________ Signature X________________________________

APPLICATION FOR MEMBERSHIP IN THE AVIATION HEALTH ASSOCIATION

THE AVIATION HEALTH ASSOCIATION is an organization whose purpose is to promote the welfare and best interests of its members; to assemble and distribute information related to the health and safety of professionals in the airline industry; and to enhance social and economic conditions for its members through cooperative enterprises as a professional or commercial association. One of the benefits of membership is eligibility for group insurances. If you are not already a member of the Aviation Health Association date and sign below.

I hereby make application for the membership in the Aviation Health Association. I certify that I currently hold a valid FM Medical Certificate that was not obtained by misstatement or concealment and that I am currently employed as a pilot or flight engineer as my primary occupation.

Date_____________________Signature X____________________________________________

AUTHORIZATION AGREEMENT FOR PRE-ARRANGED PAYMENTS (ACH DEBITS) TO HARVEY W. WATT & CO. FOR PREMIUMS DUE ON PILOT OCCUPATIONAL DISABILITY AND/OR LIFE INSURANCE

I (we) hereby authorize HARVEY W. WATT & COMPANY to initiate debt entries to my (our) Checking or Credit Union Draft account indicated below and the bank or credit union named below, hereinafter called DEPOSITORY, to debit the same to such account.

DEPOSITORY NAME____________________________________ BRANCH__________________
CITY ____________________________________________ STATE_______ZIP___________
TRANSIT/ABA NO._____________________________ ACCOUNT NO.______________________

This authority is to remain in full force and effect until Harvey W. Watt & Co. and DEPOSITORY have received written notification from me (or either of us) of its termination in such time and in such manner as to afford Harvey W. Watt & Co. and DEPOSITORY a reasonable opportunity to act on it. I (or either of us) has the right to stop payment of a debit entry by notification to DEPOSITORY at such time as to afford DEPOSITORY a reasonable opportunity to act on it prior to charging my (our) account. After account has been charged. I have the right to have the amount of an erroneous debit immediately credited to my account by DEPOSITORY, provided I (we) send written notice of such debit entry in error to DEPOSITORY within 15 days following issuance of the account statement or 45 days after posting, whichever occurs first.

I (we) further agree that any requirement for giving notice of premiums due shall be waived as long as this authorization agreement is in effect. The debit as shown on my (our) bank or credit union account statement will constitute a receipt for the premium, but no premium or portion thereof shall be deemed to have been paid unless and until Harvey W. Watt & Co. receives actual payment at its Home Office. The use of this premium payment plan shall in no way alter or amend the provisions of the policy with respect to the termination of such policy upon nonpayment of the premium due.

PLEASE PRINT

NAME(S) _______________________________EMPLOYMENT I.D.#______________

DATE _________________ SIGNED X_____________________________________

SIGNED X_________________________________________

PART II of an application for insurance to the Harvey Watt and Company

PROPOSED
INSURED:_______________________________ Birth Date _______________ () Male () Female
Last Name First Name MI Mo Day Year

STATEMENT OF HEALTH
MEDICAL HISTORY (Answer Yes or No. If Yes, give dates and details in remarks space below.)
Misstatement or omission of treatment or therapy given, can be cause for automatic rejection of this application.


1. Have you been told by a medical practitioner you had Acquired Immuno Deficiency Syndrome (AIDS) or any Immunological Disorder?	Yes No
2. Has anyone in your family (brothers, sisters, parents, grandparents) ever had high blood pressure, heart trouble, diabetes or any hereditary or genetic disease?	Yes No
3. Have you ever been denied a job, denied military service or been discharged for medical reasons?	Yes No
4. Have you ever experienced symptoms for which diagnostic evaluation was recommended, but not carried out, or failed to identify the cause of symptoms?	Yes No
5. Have you ever been hospitalized or received outpatient treatment?	Yes No
6. Have you ever had an EKG, treadmill, heart scan, or angiogram interpreted as abnormal or temporarily varied from normal?	Yes No
7. Do any of your blood relatives, e.g., father, mother, brothers, sisters, suffer from migraine headaches or other vascular-type headaches?	Yes No
8. Height (without shoes)__________ Weight (without shoes and jacket)__________
9. Name of your current insurance company for accident and sickness coverage and address of their claims department:

Have you ever been treated for, told by a medical practitioner, or had reason to suspect that you have had any of the following?
(If yes, explain in remarks section below)

10. Alcoholism or excessive drinking problem	Yes No	22. Rheumatism, arthritis or gout	Yes No
11. Asthma, allergies, bronchitis, or emphysema	Yes No	23. Reproductory organs or prostate trouble	Yes No
12. Lung trouble, shortness of breath, or tuberculosis	Yes No	24. Migraine or recurring headaches	Yes No
13. Diabetes, high or low blood sugar, or sugar in urine	Yes No	25. Back, neck, spine, or joint injury, disease or symptoms	Yes No
14. Epilepsy, fits, seizures or convulsions	Yes No	26. Mental, nervous disorder or depression	Yes No
15. Ear trouble, hearing difficulty, or ringing in ears	Yes No	27. Accidental injury; if yes, describe in remarks section	Yes No
16. Eye trouble	Yes No	28. Bone or joint injury or disease	Yes No
17. Heart trouble, irregularity, or chest pain	Yes No	29. Stomach, intestine, gallbladder, colitis, or	Yes No
18. High blood pressure on any examination	Yes No	30. jaundice trouble -- Any physical symptoms or defects now; if yes describe in remarks section	Yes No
19. Kidney -- pus, infection, stones, or blood in urine	Yes No	31. Difficulty clearing ears in flight	Yes No
20. Loss of consciousness or dizzy spells	Yes No
21. Tumor or malignancy	Yes No
32. Have you ever suffered from any symptoms, disease, injury, or received medical or surgical treatment or diagnostic evaluation for any condition not listed above?
33. Name and address of any physician including FAA examiners, therapists, chiropractors or other members of the healing arts you have consulted, received advice or treatment from in the last 10 years:
Remarks:

I hereby represent to the Company that I am a member of the Aviation Health Association or have applied for membership and my answers to the questions above are true and correct, that they shall form a part of my pending application for insurance and that if my application is accepted they shall constitute the basis of my contract with the Company and shall be a part of any such contract. I further represent that I am currently on active flight status and that to my knowledge I now suffer from no ailment, disease or disability whatever (other than those declared above) and that I am not now under the care of a physician and am taking no medicine or drugs for any ailment, disease or disability except as described above; and that I have no knowledge of any disease or infirmity that may cause me to submit a claim in the future under this Pilot Occupational Disability Policy. I understand that my insurance will not become effective until I am notified that my application for coverage is approved and premium payment for the first months coverage is received by Harvey W. Watt & Co. I further understand and agree that my coverage will become effective only if I am medically available for flight duty on the effective date and only if there has been no change in my health status since the submission of this application.
Date________________ Signature X_____________________________________

*****(REMOVE AND RETAIN FOR YOUR FILES)*****
NOTICE OF INFORMATION PRACTICES The purpose of underwriting is to assure that an applicant is eligible for insurance under the Aviation Health Association group policy issued by Great Southern Life Insurance Company.
SOURCES OF INFORMATION--In order to properly underwrite and administer your insurance we must collect a certain amount of necessary and helpful information. You provide our most important information by correctly answering questions contained in your application for insurance. For the purpose of determining that there are no medical risks of which you are unaware, we utilize various medical facilities to evaluate your current health status. The medical facility findings are forwarded to Harvey W. Watt & Co., and not retained by the examing unit.
In some instances, we may verify or obtain information by contacting professionals, your company, institutions, or other facilities who have information regarding your medical history. Our operations and records are subject to examination and audit by state and federal authorities. RELEASE OF INFORMATION -The medical information obtained is handled confidentially and access is limited to Harvey Watt & Co., and Great Southern Life Insurance Co. We do not provide medical information to your company or other institutions, such as medical information bureaus.
ACCESS AND CORRECTION - You have a right to know what information we have about you, to gain access to it (usually through a medical professional you name in case of medical information), and, if it is incorrect, to have it corrected. If you want more information about this, write to Medical Director. Harvey W. Watt & Co.. P.O. Box 20787, Atlanta. GA 30320-0787.

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