|Medical | Ailment _______________________________________________________ |
|attendance, ------------------------------------------------------------------------------------------------------------------|
|the fact | 1st Friend. | 2nd Friend. |
|should be | | (if necessary: see marginal note to |
|stated, and 10. Mention an intimate friend, who is not in- | | Question.) |
|reference terested in this Assurance, to be referred | Name ____________________ | ___________________________________ |
|given to to for information as to health and habits | Residence _______________ | ___________________________________ |
|TWO friends, of life | Profession or | |
|in answer to | Occupation ____________ | ___________________________________ |
|Question 10. | Has known him _____ years | Has known him _____ years. |
| ------------------------------------------------------------------------------------------------------------------|
|If the | Name __________________________________________________________ |
|Proposal be 11. Name, &c., of the person in whose favour | Profession or Occupation ______________________________________ |
|upon the the Assurance is to be effected? | Business Address ______________________________________________ |
|person's own | Residence _____________________________________________________ |
|life these ------------------------------------------------------------------------------------------------------------------|
|enquiries 12. Is the pecuniary interest in the Life to be | |
|need not be Assured, which is the object of this | |
|answered. Assurance, to the full amount thereof? | |
|-------------------------------------------------------------------------------------------------------------------------------|
| Sum to be Assured £_____________________________ With or without Profits? _____________________________________ |
| Is the Policy to be for Life? __________________ Are the premiums to be payable Yearly? _______________________ |
| I do hereby declare that the above statements are true, and that this Proposal and Declaration shall be the basis of |
| the contract for effecting the above-mentioned Assurance, which Assurance is also conditional on the accuracy, in all |
| respects, of the statement for the Medial Officer, made, or to be made, by the person whose life is proposed for Assurance. |
| Date __________________________________ Signature of the Person in |
| whose favour the Assur- _________________________________________________ |
| Witness _______________________________ ance is to be effected. |
| Address and Occupation ______________________________________ |
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