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Ans. i^Ybs or Na) iVjtWhat amounts are now assured on your life ? ^ ^ In what Gpmpanies, and on what Plans? O '- B! ^ I! .- n and.i'sii What Cause or Cause's. "' } "i yw Ha»«tty ottinion ever been sought from, or any consultation ever held with anj' ) ^ , Pi Physicjan or Surgeon as to whether your life was safely insurable? ji r c. If Bo^ wfts any decision or opinion given that you were, or that you tvere not safely insurable? . o t 7f^i\e that Dfite and Place of your Birth. KAY. MONTH. YEAR. PROVINCE OR COUNTRY |« 8, A. Age netif es* Birthday ? S r" Are th^ in good health? 9f*'"Nam# llllStesidence of one or more intimate friends ? II Are you married? How many dead ? How many children have you ? Cause of death? 10^ Tor W)i68e4>ei|eilt is the Assurance to be effected^? tftmttMh NAMES IH rULL.) * ■— ;_^ RELATIONSHIP TO LIFE TO BE ASSURED. OCCUPATION. P, O Conntj- . . . Province. 11; IT ISIHEIIEBY EXPRESSLY STIPULATED AND AGREED that this AppUcation, of which the statements to the Medical Eii&niner sh^ll (qnn a part, and this Agreement, with the Policy issued tbereoa, (hall iorm the contract between tlie above named persons and the said Federal Life Assurance -CoMMtNY, and that if any misrepresentation or fraudulent or untrue answer be made ; or if any fact which should be stated to the Company is suppressed therein; or if any violation of the eovenakts.^o^itipps or restrictions of the Policy [should one be issued] shall occur ; or it from any cause any payment be not made, as required by the conditions of the Policy; that then, in eith^y- event, the said Policy shall become and be null and void, and all moneys which shall have been p^d thereon shall be forfeited to the Company for its sole tfe and benefit. It is AtSO FURTHER AGREED that the continuance at the time of the delivery of the Policy, whether by mail or otherwise, t>ftl)«i«ppl!eaM in tbe same state of health as when examined, is a condition of the Assurance taking eficct, and the applicant agrees to accept the Policy when delivered, and lierAy promises to pay the first premium thereon, That if a chequf, draft, or other obligation be given for the first or any subsequent premium, or any part thereof, and if the same be not paid at maturity, it is eipressly agreed thai ijby insufkBM tfr pidicy made on this application shall thereupon become null and void, nevertheless the cheque, or obligation must be paid. ^fhat any person having or clsimtag any interest under such Policy, adopts as his or her own each and all the statements in said Application, and in this Agreement, whether '^wriHMi by HIS orHnii own hand or not, and declares the same to be full, complete and true as facts, and that such statements are the only statements upon which the Policy, shodd the insurance applied for be granted, will be founded. > -- ^ : AND THE SAID PERSON whose life is proposed for Assurance FURTHER DECLARES that he is n6t iww afSieted with any Disease or DUUttw, and that he does not now, and that he will not practice any pernicious habit that obviously tends to shorten life, and agrees to submit himself to the Company's Medical Exail)j|Q*r for the examination provided and required with this application. Dated at... .'Vte... day ef.... in presence of iSg ■* - * Signature of person or per son$\ '%'>. 4'^ ■^r-^&'t • " for whose }n"neiit the in8uranc«\ * ■ ' -'f^'^.^' is to be effected. f .h||-..v. [write names in full.] husband for \ latter, thus 'In case oi husband for wife, u> parent for children, the former may sign the/ Mary Smith 1 .u... \ by John Smith Signature of person on whom ' life insurance is IWRITE NAME erson on whom ) is applied for. > I IN FULL.] ) \ %%t4'€-'^-^- Thatt blank* mutt 6e jllM in by (he Medical Examiner. Ute Ink and be careful to anewer every queetlon fully emU plainly. The Examination thould be made In piluate. DECLARATIONS MADE TO THE MEDICAL EXAMINER ■OF THE- FEDERAL LIFE ASSURANCE COMPANY The Answen of the Api^loaiit to the Modleal HzMiilnor form an oaaontlal part of the contract. 1. Name, 1 [dSfiSe'dSSrfy] Former Occupation, 2. Ariifaa at present in good health ? Has your health been, as a rule, good? When were you last vaccinated ? 8. Hafiftf^ourecently gained or lost in weight? I If so, which? I How much? j In what time? 4. Are you, to (lie best of your knowledge and belief, free from any infirmitv, disorder, weakness or habit tending to impair your constitution or shorten your hfe? Which parent do you most resemble physically ? "^S! Are you ruptured ? ?*• A. If SO, what formTSingle or Double? b. How long duration ? 0. Is a truss habitually worn ? D. Do you promise to wear one? % Haimyou ever had in|ui,mmatbry rheumatism? B. Has the rupture ever given you any trouble? A. How often ? B. Duration of each attack ? 0. What years? D. Where there any complications i 'T. HaVe you ever had any of the following complaints? (Ybs or No to be answered to each.) jipoplexy? - Asthma? Benal or Hepatic Colic? Bronchitis? Cancer? Dropsy? Disease of Brain ? Disease of Heart? {^ase ofKidneys ? Disease of Liver ? Disease of Lungs ? Disease of Urinary Organs ? Delirium Tremens ? Diabetes ? fiischargelromEar? Dizziness or Vertigo ? Erysipelas? Fistula? Epilepsy? Fits or Convulsions ? Gravel? Gout? General'peibility? Insanity? Jaundice? Palpitation? Pneumonia or Inflammation of the Lungs? Paralysis? Piles? JWeurbyi Scrofula ? Smallpox ? Sunstroke ? Skin Disease ? Spinal Disease ? Spitting or Baising Blood ? Syphilis ? Varicose Veins ? Stricture ? Swellings or Lumps in any part ? Chronic Ulcers ? »i > i ■! ■■ 8. If jrdto rmve had any of the above or any other *$' aSment, give particulars, date, fireqneaej) and '; , tffttiOBy and attending physician. I Height. Sumurd weight FT, IN. POUNDS. ««S J I IM 5 2 "S 9 3 ISO 5 4 •35 S S 140 S 6 •43 i 7 149 i *> I4» 5 9 195 5 lo iCo I "o •69 170 6 1 •7J % Ha^e'you had any severe accident or injury, or undergone any surgical operation ? —-: T'li^ '■ '■ ^. Ar»jppu subject to dyspepsia ? A. Constipation? D.'^When Were you last confined to the house by illness, for what ? B. Diarrhoea? 0. Dysentery? 11. Do^yon drihl wine, beer or spirits ? A. How often on an average each day ? 0. Are yoii engaged in any way in the sale or manufacture of intoxicating liquors? B. Have you ever used them to excess, or been intemperate? If so, when, and for what period? D. Do you use opium, chloral or other narcotics? b. Tobacco? 12. «tteaena long aftitc^eli (BB careful to fill in HVmtY BLAMK.) avoid all indefinite terms, such as word ** CUldUrth " is used, state how lungs or other organs ? «»l»«p la, ;,, *■ [ifliiKc.} Condition of Health. Deuh. CauM of Death. How Long III ? Praviona Health. Note.— If any vague terms are used in the family nistory, explain fully here. In ease of orother or sister dyina of any hereditary disease, state wAtcA paretU ho or she resembled. If answer to ".Condition of health* be given as "Fair' or "Poor," state fully the cause. Father,^-J : Motherf4, - - - ■? I >■ 1 Brothers^ -— - I t •^^ Sisters/ I --- Father's Father, ■.■■,: / . -. ffiven at "Fair" or "Poor,' atate fully th* cause. \- Brothers< i " / — - ( Sisters/ I -- Father's Father, — • Father's Mother Motlier's Father — Mother'sMother 14. A. Has either of your parents, brothers, sisters, grandparents, uncles or aunts now, or ever had, Bheumatism? CoAsumption? Cancer? Gout? Diabetes? Epilepqr? Insanity? or other hereditary disease ? B. If BO, ffive full the parttonlars of eacn case. 15. If married, is your wife healthy and free from disease af lungs or throat? Have any of your children been so affected? I HEREBY FUBTHEB DEGL4BE that I have reai or heard read aad aBderataBd aU the ah«T« fMrtloHS pat ta »e by the Medleal Exaadaor, aai the aaiwera thereto are warraatel hy aie to he eorreet aad traO) aad that I am the person deaeribed ahore. Witnesss,. ....Person Examimd E999 If the applleaat la a womMi make a Speelal Bapdct ,f^^iilMI«k « farai la j»«orldi|l; an. the baek bereef) in addition to the Mlewla* :m:b3Idio.a-L E3:.A.]^i3sr.A.Tio2sr. 1 . How long have you known the applicant ? 2. Does h occupation affect the risk? I 8. Does applicant look older or younger than age given ? 4. Weight? Height? ft.. lbs. in. Bace? Figure? Oenerai appearance? Temperament ? Color of Hair? Color of Eyes? Complexion? Any deformities? Deaf, Dumb, Blind or Lame ? Siae of bones? 5. If under or over weight, is it a family or individual characteristic ? 6. Chest on inspiration ? inches. | Chest on expiration ? inches. I Oirth of waist? inches. 7. (The chest must be bared.) On inspection, is the chest symmetrical and well developed ? Does it expand equally well under each clavicle ? Is the percussion note over both lungs normal? Is the respiratory murmur clear and distinct over every part of both lungs? Do yon discover any indication of disease of the organs of respiration ? What are the number of respirations per minute (standing) ? 8. Are the sounds and rhythm of the heart regular and normal ? Do you discover any indication of disease of the heart or blood vessels ? f+r- w i 4t-«6 3»-»» u« 36-91 36—16 s=s 3S-«» 33— «« 3»-^ 31—75 3I-«t 30— U su; «8— It S-S »S-«6 ■»-»3 »4-d« 13 0" aj— 38 n-it 17— «» 16-96 «6— Jl lS-68 15—05 U—i* l3-«3 13— «4 ta-66 !•— 10 II— «i 9. Pulse per minute ? (Sitting) , (Standing) (If above 88 or below 54, examine at another time.) Does it intermit or become irregular ? Is the apex beat in the normal position ? 10. Condition of tongue ? I Condition of teeth? I Has he any scar or mark of identificatioaZ' 11. What is YOUB OPINION as to the extent of his use of intoxicating liquors or narcotibs either now or in the past? 12. Is urine normal in quanity and appearance ? Does he have to rise at night to pass it ? (Urine to be examined in all cases.) 18. Color. Beaction. Specific Gravi^. Albumen. Sugar. Deposits. If f6ijnd alkaline or neutral, give reason. 14. Do you find the applicant in perfect healtii and safely insurable ? 15. Do you consider the applicant a F1B8T-CLA88 risk— a ttOOD risk— or oaly a FilB risk f LL 16. Do you think he will survive the "Expectation" as shown by the table in the margin ? If JOB have aay hesltatloa la deetdinf, five the Gompaay the beaelt of the doabt aad aaswer, *' ^ • •'■•■■ \ «« : ■^ '•■■■ '--: -r , w - f- . s mm a : f; m ■ i 2 f 'i : « 1 * 1 ^ ; jM "^ : ' -■. w r ',:. 1h '^ <& I 1 a; 2 I ♦ I % 4? L •s : ^•. '.3 .^ V, 1 S 3 ADDITIONAL STATEMENTS TO THE MEDICAL EXAMINER WHEN THE APPLICANT IS A WOMAN. . ■ ZS^ . ,•' '■ -^ZZ* : = ■-;'-• t . » Have you passed the change of life ? If married, how long ? ^ Were labors difficult ? ^ Have you ever been treated for womb disease? If so, when, and by whom? Have you any disease of the breast? j Husband's occupation ? r ii If not, are tlie uterine functions regular in all respects? HAw many children ? How often miscarried? 'i How long since birth of last child? ^ ^ , Are you now pragnant ? ( ___ ■I t r ji « His state of health? The foregolnff statementa are trae to the .best of my knowledge and belief. j \ j u I '..■ . I ! ; t I hare eareftallj examined the applicant and bellere her statements ) and the answers glren abore to be eorreet and true. 5 -~ «- «• ^.1 V -',^/.; "T'' '•w* ^ fi ^m* ^ J5 I- rO ■. ■-Si'■c^ 1 - n ,-f '■■ ^ "^ ■-,^0^ '^..a Applicant. M D.