|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 |