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Show First Class Permit No. 27416 Philadelphia, Pa. . BUSINESS REPLY MAIL No postage necessary if mailed in the United States POSTAGE WILL BE PAID BY — The PRESIDENTIAL LIFE INSURANCECO. OF AMERICA 11401 Roosevelt Blvd. Philadelphia, Pa. 19154 25¢ ENROLLMENT-APPLICATION ON THIS PAGE MUST BE MAILED BY MIDNIGHT OF DATE SHOWN ON FORM. THE SOONER YOU MAIL IT, THE SOONER YOUR PROTECTION STARTS. COMPLETE AND MAIL UU PAT 7 MacuetaalNTae a UTA SHSUIADIDTOOANONNASSCAN XX) S NAS IAOAROAAAAACN 8x2 NAA CAO OK KOK HH HX ) Application to: The Presidential Life Insurance Company of America, Chicago, Ill., for The Presidential Extra Cash Hospital Plan. 6 0 Please Print). Rs, is _ NAME(Please Prin First Middle Initial last ADDRESS. Street or RD # ae eS(hEIP DATEOE SR AGE_______SEX Male [] Female [) Month Day Year OCCUPATION List all dependents to be covered underthis plan, (D0 NOTinclude name that appears above. Use separate sheetif necessary.) DATE OF BIRTH NAME RELATIONSHIP. SEX () Checkhereif you want Coverage for your Children. (] Check hereif you want Coverage for your Children and Maternity Benefits. To the best of my knowledge andbelief neither | nor any personlisted above has been refused or had cancelled any health, hospital orlife insurance Coverage due to reasons of health.| hereby apply for the Extra Cash Hospital Plan. | understand that |, and any person listed above,will be covered underthis Policy for a recurrence of anyinjury or sickness | (we) had before the Effective Date of this Policy after two years from Effective Date, but not before; and that this Policy shall not be in forceuntil the Effective Date shown in the Policy Schedule. | am enclosing $.25 for the first month's premium for coverage for myself and all other | Family Memberslisted above. | SignatureX. Prete Ak vP623 Date Heldseee ee es Seca MAIL ENROLLMENT FORM BEFORE MIDNIGHT, SATURDAY, APRIL 26, 1969 W WH FAP 35L86 |