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Show NA ella, HOME =a Official Enrollment Form for the Hospitalization Indemnity Pian = = NATHONAL HOME LIFE ASSURANCE COMPANY = An Old Line Legal Reserve Companyof St. Louis, Missouri ADMINISYRATIVE OFFICE: VALLEY FORGE, PENNSYLVANIA Please Print 8-1306-9-01 MR. _— Mise First Middletnitiat ADDRESS Last Street or RD city STATE. DATE OF BIRTH Month Day Year ZIP. AGE. SEX MaleO FemaleO OCCUPATION. List all ee to be covered under this Plan. (DO NCT include name that appears above. Use separate sheetif necessary.) NAME(Please Print) ) Check here if you want Coverage for Your Children. RELATIONSHIP SEX Month Day Year| AGE O) Check here if you want Coverage for Your Children and Matomity Benefits. | hereby enroil 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 my knowledge and belief neither | nor any person listed above has been refused cr had cancelied any health, hospital orlife ge due to of health. | understand that this Policy will become effective when Issued and that pre-existing conditions wilt be covered after two years. Sig x. Date NHA-10 NH10-669EP (500) Cal. SSN H1016 wD 10H THT TTT TTT TT TTT TTT eT e rece cece e cee eee MAIL THIS ENROLLMENT FORM BEFORE MIDNIGHT,JAN. 13, 1971 Family Weekly, January 3, 1971 f anetty rr very eer We will send your National Home policy by mall. Examine it carefully in the privacy of your own home. Show it, if you wee to your ownete agent, doctor,sie or other trusted advisor. if you decide, for any Bans that you to continue as a memberof this tise, retum the policy within 15 days, and we will promptly refund your money. Meanwhile, Hosielog be fully protected while making your 4, |