Disability Insurance

Name
Date Of Birth
Address
City
State
Zip
Country
Email Address
CellPhone
HomePhone
Occupation
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


R.J. Mellusi / Rjmellusi@sealawyers.com
29 Broadway / New York, N.Y. 10006 / U S A
Voice 1-800-280-1590 / Fax 1-212-385-0920