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Show And Mail with JUST $100 Behe ark ys i NMCa Lea nae oelas ' ECO eeecat Coma Dans a OFFICIAL ENROLLMENT FORM Dats) ed Coa Tory CME sL 811) Dept. 2362 360 West Jackson Bivd. APPLICATION TO NATIONAL-BEN FRANKL LIFE INSURANCE CORPORATION,CHICAGO, ILLINOIS Please Print EN, ee, a a First Middle Initia! Last (mo./day/rr.) ADDRESS. CITY. SOCIAL SECURITY NO. STATE List all dependents to be covered. Use separate sheet for additional children. NAME (PLEASE PRINT) to NATIONAL-BEN FRANKLIN LIFE DATE OF “RTH(mo./day yr.) Spouse. ZIP CODE. NAME (PLEASE PRINT) DATE OFBIRTH (mo./day/yr.) Child Child child Child Child 1 represent that neither I nor my spouse, if listed above, has been hospitalized due to sickness for a total of more than seven days in the last two years. I agree that if both husband andwife are covered, the husband will be the Insured. I understand that coverage will take effect whenthe policy is issued. DATE. SIGNATURE. 4801 NBL i] Please make check or money order payable to N-BF Life Chicago,Ill. 60606 National-Ben Franklin Life Insurance Corporation NationalBen Franklin Life Carries Full Legal Reserves For the P.otection of All Insured Established 1852 |