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Show Non ms Valley Forge Pe ee Official Enrollment Form for the Hospitalization Indemnity Plan NATIONAL HOMELIFE ASSURANCE COMPANY An Old Line Legal Reserve Companyof St. Louis, Missouri ADMINISTRATIVE OFFICE: VALLEY FORGE, PENNSYLVANIA 2-1351-9-01 Please Print MPWEY-BACK GUARANTEE NAME Mrs. Miss Fire? Middle Initiar ADDRESS Last We will send your National Home policy by mail. Examine it carefully in the privacy of your own home. Show it, if you wish, to your own insurance Street or RD# CITY STATE DATE OF BIRTH AGE Month Day agent, doctor, lawyer or other trusted advisor. If decide, for any reason, that you don't want § zip SEX Mais 0 Female 0 Year List all dependents to be covered under this Plan. (DO NOT include name that appears above. Use separate sheet if necessary.) SEX DATE OF BIRTH Month Day ‘fear AGE in) m/co |r| RELATIONSHIP OD Check here if you want Coverage for Your Children. (CO Check here if you want Coverage for Your Children end Matemity Benefits. | 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 my knowledge andbelief neither | nor any personlisted above has been refused or had cancelled any health, hospital orlife ge due to of health. | understand that this Policy will become effective when issued and that pre-existing conditions will be covered after two years. Signature X. Date NHA-10 NH10-669 EP 5 (500) COTTA CTT OTT eee eco eee eee ee eee ee Tee eee aeee MAIL THIS ENROLLMENT FORM BEFORE MIDNIGHT, APRIL 14, 1971 vevyy H1205 126 Family Weekly, April 11,1971 your money. Meanwhile, you will be fully pro- tected while making your decision! OCCUPATION NAME(Please Print) to continue as a member of this nian, return the policy within 15 days, and we will promptly refund vuvvy = 4 TrRhett wished PRESIDENT National Home Life Assyrance Company > |