High Point Enterprise Newspaper Archives Aug 13 1972, Page 115

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High Point Enterprise (Newspaper) - August 13, 1972, High Point, North Carolina Confidential application form application to National Ben Franklin life insurance corporation Ner Chicago. Illinois 60606 for a lift insurance policy providing insurance As Fonos i term Ute insurance in Aas 70 insured 0 $ 5,000 0 $15,000 0 $10,000 0 $20,000 spouse coverage May not be More then it the amount for the insured 0 $ 2.500 o $ 7.600 0 $ 5.000 o $10,000 children s coverage 0 look premiums 0 annually to be payable 0 quarterly 0 set Ennu aty 0 monthly i. Your full name City end Stem _ Detent birth _ Street address zip code piece of birth height social Security number. Weight _ sex present occupy Tom spouse s name _ employers dem of birth piece of birth height weight names and dates of birth of children beneficiary of insurance on your life relationship Nom the proposed insured shul be the beneficiary for any insurance on the life of the spouse end children Are of persons proposed for insurance now. To the Best of your knowledge end belief in Good Heath end free from any physic a or Manta impairment deformity or abnormdity7 0 yes 0 no of Quot no Quot give name of person end details continue on separate h needed. I 6. Hee any person proposed tor insurance been Hospital red or consulted any doctor in the past 5 yams 0 yes 0 no of Quot yes Quot give names of persons mesons dates names end addresses of doctors and of Hospital if any continue on separate Sheet. I Ballf to a. A a departs 7. Name end Edrem of family doctor 8. Is the policy Turtle for herein intended to replace or change insurance carried in this or any other company of Quot yes Quot five companies plan and amount to the Best of my knowledge the information in this application including any attached con tiny a Ion of it is True end Complete i agree that n8f Shat incur no liability because of this application unless and until it is approved by Jbf and a policy is issued i hereby authorise any physician Hospital dime insurance company or other org Emarion institution or person that has any records or knowledge of me my spouse or any of my children to give to Jbf any and Ai information about our Heath end Medica history and any hopi action advice diagnosis Trtat Mant. Disease or ailment a photocopy of this authorization Shat be Vaid As the original. Date Day Yaar signature of proposed insured will be owner of pacy agent s signature 5068a nil pm make Check or Money order payable to Jbf life 6032 Complete lid mail a 1st months to h. L Thompson . On 11201_ Charlotte n. C. 28209 the 120 year olo National Ben Franklin life insurance Cert oration Isa member of k the h Continental corporation a Stam Eliod i l 1852 a Cie amp he family weekly August 1t1v2

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