Independent from Long Beach, California • 153

07 v. A taA I IKS I II I II4S i ri. $1,200.00 A MONTH ($40.00 A DAY) Plan A oo $900.00 A A DAY) A K. PlanB Qoi NATIONAL HOMF I II ASSLRANC O. 6133-3 -ADMW1S TRATlVlUy I Kfc VAli.ty 1 ORGM'liNNSlLVANU- MR.

Name (Please Printl MISS MM. iMkiuie inuiui sircei.or kij it siaie ip I vnialc Male i Date nf Birlh- Age. 1 i. i 1 1 if -s. 1 5 Year Month Day Check here it you want Coverage for your Children.

t-i iwi wm mm I overact wir tour niiarcn ana List all depemlifliis UT be covered under this Phiir.ilX NO I include nanie that appears ahove. Use separate sncci ii ncvxsNai i DA I OK HIK1II KF.X Yr.AR DAY MOM II KII.AIION-NAfK irirake Prial) smp 1 4 5 0 become effective when issued. I also I understand that the policy wi i understand that drty injury or sickness for which I or any person listed have' been medically advised or treated during the 12 -month peri.Kl immediately prior til the" I-ITective Date of overage will not he cov- cred during the first year. Dale Signature nii si imi cm. iro NHAM172rAJ-l H6097-CA mi aiiiiol lie luriu-d Huwii.

-J- a i 04-3 M'Z i r-e- 6133-3 05-0 02-7.