| on the ___________________________ day of _______________ in the year 18_________ |
| (Evidence to be produced.) |
| ------------------------------------------------------------------------------------------------------------------|
| 3. Has he resided out of Europe? | |
| If so, where, and for what period? | |
| ------------------------------------------------------------------------------------------------------------------|
| 4. Is he, and has he always been, of sober and | |
| temperate habits? | |
| ------------------------------------------------------------------------------------------------------------------|
| 5. Has he had any serious illness or disease | |
| tending to shorten life? | |
| ------------------------------------------------------------------------------------------------------------------|
| 6. Has any near relative died of any hereditary| |
| disease? | |
| ------------------------------------------------------------------------------------------------------------------|
| 7. (1) Has a proposal to effect an Assurance on| |
| his life ever been declined? |_________________________________________________________________|
| (2) Or accepted at more than the ordinary | |
| rate? |_________________________________________________________________|
| (3) If so, on how many occasions, and | |
| when, and by what office or offices? | |
| ------------------------------------------------------------------------------------------------------------------|
| 8. Is there any other circumstance which ought | |
| to be communicated in order to enable the | |
| Company to judge fairly of the risk? | |
| ------------------------------------------------------------------------------------------------------------------|
|If the | Name __________________________________________________________ |
|person has 9. (1) Who is his usual Medical Attendant? | Residence _____________________________________________________ |
|never | Has known him ________________ years. |
|required (2) When was he last in professional atten- | Date of Attendance ____________________________________________ |