Sunday Gazette-Mail from Charleston, West Virginia on July 30, 1972 · Page 109
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Sunday Gazette-Mail from Charleston, West Virginia · Page 109

Charleston, West Virginia
Issue Date:
Sunday, July 30, 1972
Page 109
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Act now* Offer expires midnight Wednesday, August 2, 1972 7-4605 7-4610 ' Be sure to check off I which plan you want: I LJ $500 a month I I I I I I $1,000 a month OFFICIAL APPLICATION FORM Academy Life Insurance Company Administrative Offices, Valley Forge, Pa. 19481 Mr. Name Mrs. -- Miss (X Address .. . . . 3 C i t y . . . . CL Date of Birth .___ ...... ______ ____ ____ ..... . .____ ___________ First (Ladies, use your own first name) Middle Initial Last Street or R. D. No. State -- Z i p . Age. Month Day Year I wish to include the members of my family listed below. (Do not repeat above name.) Sex: Male D Female Q Name ( Please Print) 1 2 3 4 5 Relationship Sex Date of Birth Month Day Year Age I hereby apply to Academy Life Insurance Company. I understand my coverage will take effect on the E f f e c t i v e Date shown m the Policy Schedule. I further understand that injury or sickness suffered before the Effective Date will be covered a f t e r the Policy has been in force two years and that new conditions are covered immediately i i i i i i i i Academy Life Insurance Company Administrative Offices: Valley Forge, Pa. 19481 Licensed in the State of West Virginia

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