OCR Text |
Show i 1 ; 1 ", i ..or pays you : : yi iUA: nut. iAk.piii s20.00aday for as long as you are hospitalized. OFFICIAL ENROLLMENT FORM iriinacsLTr3arac3C!C3nEar2E3E3ac3C3r Official y n px P- -1 tJ n r Enrollment Form for the Hospitalization Indemnity Plan NATIONAL HOME LIFE ASSURANCE COMPANY An Old Line Legal Reserve Company of St. Louis, Missouri ADMINISTRATIVE OFFICES: VALLEY FORGE, PENNSYLVANIA (Please Print) MR Name mrs Middle Initial First MISS 0 a . Street or RD U H i, -- State City- - Sex Male Female Li Occupation P List all dependents to be coveredif under this Plan: (DO NOT include name that ap pears above. Use separate sheet necessary.) y n r?. Director, National Home Life Assurance Co. m HOW TO GET YOUR POLICY Di: J CS 2. 3. C Complete this brief Enrollment Form. Fold and tear along dotted line. Enclose Form and quarter in reply envelope inNATIONAL HOME, Valley Forge, Pa. 19481 side and mail to 1972, National Liberty Corporation Copyright Ef G Q Check here if you want Coverage for Your Children. D Check here if y ou want Coverage for Your Children and Maternity Benefits. I hereby enroll in National Home's Hospital Plan and am enclosing the first month's premium to cover myself and all other Covered Members listed above. To the best of r my knowledge and belief neither I nor any person listed above has been refused or M had cancelled any health, hospital or life insurance coverage due to reasons of health. D I understand that this Policy will become effective when issued and that E conditions will be covered after two years. 0 n 0 0 4 test u pre-existi- U efficiently. Believe me, when you need them, they'll be there to help you. Cil ai 0 r National Home. And you won't find more decent, friendly people to deal with. I've seen the way they handle claims, too quickly and 0 -- Zip- Date of Birth. : I've made a point of getting to know the folks at 0 Last Address Dear Friend Signature -- 0 u Date. NH H3144R-U- ' ' 1 " ' 1 ' ' r EP 3 (600) NAL HOME HEALTH PLAN.. National Home Life Assurance Company a member of the National Liberty Group Adm. Offices: Valley Forge, Pennsylvania 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 cariies full legal reserves for the protection of all policyowners. Established 1820-O- ver BO Tears of Reliable Service LICENSED BY THE STATE OF UTAH |