| 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 ____________________________________________ | |Medical | Ailment _______________________________________________________ | |attendance, ------------------------------------------------------------------------------------------------------------------| |the fact | 1st Friend. | 2nd Friend. |