William Penn Life, 1994 (29. évfolyam, 1-12. szám)

1994-09-01 / 9. szám

September 1994, William Penn Life, Page 7 Application for Single Premium Whole Life and $20,000.00 Juvenile Term to Age 25 Insurance Plans IMPORTANT WILLIAM PENN ASSOCIATION A FRATERNAL BENEFIT SOCIETY • SINCE 1886 SECTION A Pittsburgh, Pennsylvania 15233 1. Proposed First Name Middle Last □ M Insured: □ F 14. a. Plan: (describe fully) 2. Residence Street City State Zip Address: b. Face Amount: ; or amount purchased hy (mode) premium of $ 3. Date of 4. Place of Birth Birth: (Mo-Day-Yr) State or Country: 5. Marital Status: c. Include Rider Benefits: D ADB, Amount DWP DGPO, Amount D Payor DFamily Bene., Units DRPO D FPA, form no. D Auto. Prem. Pymt. D Yes D No D Deer. Term, form no. D Yrs.__Initial Amount 6. Occupation: 7. How long at present occupation: 8. Beneficiary: (Show name and relationship to Proposed Insured) Primary: Contingent: 9. Do you intend to fly; or, have you flown within the past 2 years as a pilot, or crew member? YesD NoD If "yes” will you accept an exclusion rider? YesD NoD If not, complete an aviation questionnaire. 15. (a) Premiums to be paid: DAnn. D Semi-Ann. DQtrly DMonthly (b) Automatic Prem. Loan: DYes D No (c) Amount paid with App.: $ 10. Is this insurance being purchased to replace or change any existing insurance or any annuity? Yes D No D If "yes” what company and policy number? 16. Requested Certificate Date (If none shown, Requested Date will be the later date of this application or any required medical examination.) Certificate years and anniversaries will be computed from the Certificate Date. / / 11. Have you ever been treated or counseled for: alcoholism; or, used marijuana, LSD, or heroin? Yes D No D If "yes" give details on separate memo. 12. Insurance now in force: Life ADB 13. Home Office Use Only month day year SECTION B. Additional Information Regarding the Proposed Insured. 1. HEIGHT:___Ft____In. 2. WEIGHT:_____Lbs. 3. Give weight gained or lost in past year:_____Reason. 4. Have you had or been told you had: Yes No a. Asthma; emphysema; or, other lung or respiratory disease or disorder?........................................... D D 5. Have you, within the last five years, had an: Yes No electrocardiogram; X-ray; blood study or, other special diagnostic test?...................................................... D D b. Any disease or disorder of the brain or nervous sys­tem? ............................................................... D D c. Kidney disease; diabetes; or, other disease or disorder of the genitourinary system?................................ D D d. High blood pressure; chest pain; rheumatic fever; heart disease; or, other circulatory disease or disorder?.. . D D 6. Have you been under: observation, care or treatment in any: hospital; sanitarium; or, othei institution?.......... D D 7. Have your applications for life or health insurance ever been: declined; postponed; or, modified?.................. D D 8. Do you have other applications for life or health insurance now pending?........................................................ D D e. Ulcer; disease or disorder of the stomach, liver or in­testines?........................................................... D D f. Tumor or any malignancy?.................................... D D g. Deformity; lamness; or, any physical or mental impair­ment? ............................................................. D D h. Any surgical operations;..................................... D D i. Any other injury, disease or disorder in the past five years?............................................................. D D 9. a. Have you had any disease or disorder of the breast or reproductive organs?.......................................... D D b. Are you pregnant? (How far advanced?) 10. Name and address of personal doctor Date and reason last consulted 11. Give details regarding any "yes" for Questions 4 through 9. (please print) Question Illness Name & Addresses of Degree of Number Injury Date Doctors & Hospitals Recovery 12. Dividend Election: DCash D Reduce Premiums D Paid-Up Ins. DAccumulate DOne Year Term Addition 13. Is the Proposed Insured a member of the William Penn Association?DYes DNo If not, apply for membership. Having read the above statements and answers, I represent that, to the best of my knowledge and belief, the answers to the statements are true and complete. I agree that: (1) this application and any supplement or continuation thereof shall be the basis for and a part of any insurance contract issued: (a) on the basis applied for; (b) on a basis other than as applied for; or (c) with an endorsement in the Home Office section above; and (2) except as may be otherwise provided in a Conditional Receipt bearing the same date as this application, no insurance shall take effect until: (a) a certificate is issued and delivered to me; (b) the full first premium thereon is paid; and (c) all while the health and other conditions affecting the insurability of each person on whom insurance is requested remain as described in this application; and (3) unless otherwise stated in this application, the Owner of the insurance contract shall be: (a) the Applicant, if other than the Proposed Insured; or (b) the Proposed Insured. I understand that: (1) no information acquired by an agent or representat ive of the William Penn Association shall bind the William Penn Association unless set out in writing in this application; (2) no agent or person other than an officer of the William Penn Association is authorized to: (a) make or modify contracts; or (b) waive any of the rights or requirements of the William Penn Association; and (3) in those states where statutes or regulations so require, the following changes will be made in this application only with my written consent: (a) Plan; (b) Amount; (c) Classification of Risk; (d) Age; or (e) Ben­efits. Application made at ________________________________________this ________________day of______________ 19 Signatures: Proposed Insured: ______________________________________ Witness _____________________________________ (licensed agent) Proposed Insured’sSoc. Sec. No____________________ * Adult Applicant and Owner or Member Applicant: Form No. AC-9-81 Applicant MUST sign the Authorization below and submit it with Application. < 5 d) CDO < E o-C c c O “ o 3 m Q. .tr c § || 0 O "g sS-5- o C 0) ^ CO u 03 § n (/) -3 C .£ - £ tr o o o -c i CO CL W 0 0 0 CO o(1) £o 00 CO O C O m CO COC 0"co O co 3 E 3 o SI- 0 1" S .2 coS -2 -s; © O) cCO 05o CO- CO 0 "O isco Ö EO o 0> CO «1O (D _ 2 C CO — o O D i_ CO o >, 0 0 = o O0 --­- n c o: co *•” jO.cS - =3 £ 5: co n > : 0 O 0- co o 0CO CO SB­E.E 1° o CO "O o . 0 ° C CO ._ ~~ co CO 5 < Ü c. C CO 0 CL 05-O o t: -c o o — c .c Ö co c Q- p- U 0 CO b T3 05 0 0 C O C 0 = -C 0 .C > °-o) tr > © co o 05 o0 o o _ 3 0- TO < 0 o b. -C ^-C 2 o “ 0< N -= _ 0 > 0 “S 2 £> CCo X F­D < lit 0 ° 'S y c ^ OC P 0 c C er| ■i°l o|| _ 3 0 0 O 0 [ •*- C —U C ° .2 C CO TD C 0 © ~ 3 0 N ~r-\ "O st C I 2 .■= 05 O g. C O o 0 B c CO C F N 0 t — L= 0^00 05 o < 0sn 0 0 -Q .CO £ £ ^£ gslffl : £ «cc 0 O <S -c oo c\i ^ -o' tr o © 0 ®-l °-1 3 0 CO . 05 J O JO c 2T O 0 "O-- 0 0 « -- y 0CM CO o ^ >* C -C 0 ® P-5CO c 0 c o o0 3 0o T3 0 E o c0 O 0c o 0 -liE 2 cn'S <l) c o ro co “. 0)>.l =3 2 ® u, OT ^ E C £ O E I =5 .E O CO 0 0 *•“ § EÖ 8 C Co IS0 - O O <D E 9 F O ~ 0 0 j: c "- "■ 05 >s "o E£ Q) CO Q.-I ■o O 0 (/j Sp 0 w — O U -Qo — CJ E 05 >3 "q3 0 o e "I s : 2 § CL 3 b c 0 co -JC o c C o X t (0 CD 2? O _ >."ä| l&S'l 0 C cd N ■o.o O 0-1« §£ ^ O 0 < 0 CO .2 .CO o < CD -C D c O c ® o CO 0 -O = °- C Q. < E P o N «0 c Eng 0 g'© 1 0 0 0 "O D< >-m LU cc Q. "O E 0 o c ®1 s úi g o 5 KJ 3_ — — 0 o 0 CC £ c O obi 2 !«>,> 3 o - E < 2 o — 0 3“« 5 lő S 0O c 0 Q.CL 0 0 -C •o0 ■o _o o o Q.CO co "O 0 oCL O o0 05 CO c0 OCL 0 01 0 o■O 0 OCL o O0 05 in 00 Q Name(s) of Juvenile Proposed Insured(s)

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