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Show This form and 250 could provide you tax-fre- e cash to help pay your hospital, medical, and surgical bills. OFFICIAL ENROLLMENT FORM Plan Enrollment Form for the NATIONAL HOME LIFE ASSURANCE COMPANY Official An Old Line Legal Reserve Company of St. Louis. Missouri ADMINISTRATIVE OFFICES: VALLEY FORGE, PENNSYLVANIA (Please Print) MR NAME Muss. Last Middle Initial First ADDRESS. Street or RD - STATE. CITY zip. Female SEX Male DATE OF BIRTH. Month Year Day List all dependents to be covered under this Plan: (DO NOT include name that appears above. Use separate sheet if necessary.) you want coverage for your children. I hereby enroll in the National Home Plan. To the best of my knowledge and belief neither I nor any person listed above has been refused or had cancelled any health, hospital or life insurance coverage due to reasons of health: i understand that this Policy will become effective when issued, conditions will be covered after two years, and new conditions will be covered immediately. Check here if Medical-Surgical-Hospi- pre-existi- Signature X. .Date. NH191071 NHA-1- i t I 1 . Vi . iw : ; ' I ft V ,f :.i-- M'LiMOHf, MAY 2.i, 1972 2508 M2266 National Home Life Assurance Company NAL HOME HEALTH PLAN. a member of the National Liberty Group Adm. Offices: Valley Forge, Pennsylvania Established 1920 Over 50 Years of Reliable Service This policy is underwritten by National Home Life Assurance Company, an old line legal reserve company of St. Louis, Missouri. National Home is licensed in 46 states and carries full legal reserves for the protection of all policyowners. Copyright 972 National Liberty Corporation LICENSED BY THE STATE OF UTAH |