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Show ATT RL CLM an, a PALLae . Official Enrollment Form for the Hospitalization fieryPlan NATIONAL HOMELIFE.ASSURANCE COMPANY An Old Line Legal Reserve Companyof St. Louis, Missouri ADMINISTRATIVE OFFICE:VALLEY FORGE, PENNSYLVANIA Please Print MR, NAME was. MISS First 4-1456-5.01 MiddleInitial ADDRESS Lest Street or RO city STATE DATE OF BIRTH Month Day zp AGE Year SEX Male © Female 0 OCCUPATION List all de>endents to be covered under this Plan. (DO NOTinclude name that appears above. Use separate sheetif cessalry.) assess NAME (Please Print) Check here if you want Coverage for Your Children. RELATIONSHIP | SEX DATE OFBIR H | Month Day | Year | AGE (Checkhore i you want Coverage for Your Children and Maternity Benefits. | hereby enroll in Netional 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 beenrefused or had cancelled any heaith, hospital orlife insurance coverage due to reasons of health. | understand that this Policy will become effective whenissued and that pre-existing conditions will be covered after two years. Signature X NHA-10 Date NH10-S69EPS5 (600)Cal. DE NtSOS Ole ASRSSSASLGEASCCOasomenFaseronewwe, Oc18,1271 COUT H1438 USE THIS COUPON IF YOU ARE 65 OR OVER 4-1456-5.01 Please send me complete information on your special health plan for =e 65 or over. | rand obligation ...no cost. - and no salesman oragentwill call. Please Prine NAME, ADDRESS. ony. STATE AGE. DATE OF BIRTH. U Eetabliahed 1920-Over 50Yearsof RalisbleService FILL OUT THE ENROLLMENT FORM ‘ANDRETURN TODAY ; |