Description of Highest License

If you are not licensed state description of Highest MMD rating

What license oe MMD rating do you customarily sail under?

State gross earnings for prior year.

Estimate expected gross earings for current year.

Desired Monthly Benefit (i.e. how much monthly income do you want to receive if disabled)

Benefit period

Elimination period

Do you request Optional Cola Rider to increase monthly benefits?

Do you request optional Residual Disability Rider?

Are you currently Fit for Seaduty?

Have you ever been declare NFFD (not fit for duty) in the past 3 years? If so state the condition, and period of time NFFD.

NFFD - Condition and Time