FURTHER OFFICIAL FORMS OF FIRE AND LIFE INSURANCE. [FROM JAMES ON LIFE AND FIRE ASSURANCE.] FORM NO. I. Proposal for Fire Insurance. ASSURANCE SOCIETY. Particulars required from a Person who proposes to Insure Property against Fire CLASS FORM No. 2. Proposal for Life Assurance. ASSURANCE SOCIETY, TABLE Particulars required from a Person who Proposes to Assure his own Life with this Society. 1. Name, residence, and profession, or occupation of the person proposing the assurance 2. Name, residence, and profession or occupation of the person whose life is to be insured 3. Whether in business on his own account? or in whose employ, and how long? 4. If a householder or lodger, and how long? (State name and address of landlord) 5. Place and date of birth. (State parish, town, and county) 6. Age next birthday 7. Whether the party is now in good health 8. Whether the habits of the party are, and have been, sober and temperate 9. Whether the party has ever been afflicted with apoplexy, palsy, fits, convulsions, spitting of blood, habitual cough, asthma, palpitation of the heart, or consumption 10. Whether the party has ever been subject to rheumatism, gout, insanity, rupture, or any other disease or infirmity tending to shorten life. (If so, its nature and extent to be stated) 11. Whether any member of the party's family has died of the discases named in the two foregoing queries: that is, either father, mother, brother, or sister. (If answered in the affirmative, particulars to be stated) 12. Whether the party has had the smallpox or the cowpox from vaccination. (State which) 13. Whether the party has ever resided abroad; where, for what period, and how long since 14. Whether the party will attend personally at the chief office, or at a district office 15. Is the party's life now assured at any other office; if so, in what office? State as near as possible the date when such assurance was effected, and if taken at the ordinary, or at an increased rate of premium 16. Has the party's life been declined by any other office; if so, state the name of the office, and about the time it was declined 17. Whether the party is, or has ever been, employed in the military, naval, merchant seamen's, or preventive service 18. Reference to two respectable persons who are competent to afford information as to the identity, the state of health, and mode of life of the party 1st The usual me- friend or ac- Name Address Name If the party has no medical attendant, then give the name, occupation, and address of another intimate friend, who can speak as to the party's health and mode of life.. 19. Sum proposed to be assured, and the nature of the assurance, [Words at length.] I hereby propose to effect an assurance with the [Seeptre] Assurance Society, of the nature described in Clause No. 19 of the above particulars; and I do hereby declare that I have not withheld any information which is calculated to influence the decision of the Directors as to the eligibility of my Life for such assurance. And I do further agree that the assurance hereby proposed shall not be binding on the society until the amount of premium demanded shall have been paid. Dated this day of 18 Name and address of [Signed] [When an assurance is required to be made payable on the death of the first or last of two lives, a separate proposal must be filled in and be signed by each of the parties; and the nature of the assurance, whether payable upon the death of the first or last of the two lives mentioned, must be stated in Clause No. 19.] *If the assurance be intended to be paid on the person attaining a given age, or any previous death, it must be so stated. * Queries 3 and 4 are only required in Proposals for the Industrial Classes, FORM No. 3. Proposal for an Endowmeat. ASSURANCE SOCIETY. LIFE DEPARTMENT. Particulars required from a Person who proposes to Purchase an Endowment with this Society, payable upon the Person Endowed surviving a given age. 1. Name, Residence, and Profession or Occupation of the Person proposing to purchase the En- } When payable? At [Here state a day in the year immediately following the birthday at which the Endowment is required to be paid, the deferred term comprising a given number of whole years from the date of the proposal.] Whether Premiums will be paid Yearly, Half Yearly, or Quarterly I, the undersigned } hereby propose to purchase an Endowment for the sum of £ on behalf of with the [Sceptre] Assurance Society, upon the terms above specified; I do furthermore agree that this Proposal and Declaration shall be the basis of the contract betwcen myself and the said Society; and I hereby certify that the whole of the foregoing particulars are true. Such Endowment to be subject and liable to the Conditions and Stipulations of the said Society, in that behalf made and provided. FORM NO. 4. Proposal for a Deferred Annuity. ASSURANCE SOCIETY. 1. H The Person proposing to purchase a Deferred Annuity, must state: Name, Residence, and Occupation being desirous of purchasing a Deferred Annuity, as before described, on the Life of from the [Sceptre] Assurance Society, do hereby declare that the age of exceed years on the will not day of next, and that the several particulars of the above pro- posals are true. Dated this Witness NO MEDICAL EXAMINATION REQUIRED. 18 A Copy of the Certificate of the Birth of the Person on whose Life the Annuity is to be granted (or some other collateral evidence), will be required to be lodged with the Society. FORM No. 5. Proposals for an Immediate Annuity, or Annuity Assurance. ASSURANCE SOCIETY. The Person proposing to purchase an Immediate Annuity, or Annuity-Assurance, do hereby declare that the several particulars of the above proposals are true. Dated this day of 18 Witness NO MEDICAL EXAMINATION REQUIRED. A Copy of the Certificate of the Birth of the Person on whose Life the Annuity, or Annuity-Assurance, is to be granted, (or some other collateral evidence,) will be required to be lodged with the Society. The purchase of an Annuity involves the sinking of the entire sum paid down; but not so that of an Annuity-Assurance, the whole, or an agreed portion of it, being returned to the representatives of the Annuitant on death. |