Sunday Gazette-Mail from Charleston, West Virginia on August 27, 1972 · Page 106
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Sunday Gazette-Mail from Charleston, West Virginia · Page 106

Charleston, West Virginia
Issue Date:
Sunday, August 27, 1972
Page 106
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Page 106 article text (OCR)

Act now. Offer expires midnight Wednesday, August 30,1972 a^^^^^^^ ii^^^^^^M ^^^^M^H · Be sure to check off | which plan you want: LJ $500 a month ^^605 LJ $1,000 a month I I i I I I OFFICIAL APPLICATION FORM Academy Life Insurance Company Administrative Offices, Valley Forge, Pa. 19481 Mr. Name Mrs. 21-6 I I I I I Miss First (Ladies, use your own first name) Middle Initial ; Address _ Street or R. D. No. ' C i t y . . . state _ _ . ' . . Last Date of Birth. ---- A ec Sex: Male Q Female Q Y Q 3 r Month Day I wish to include the members of my family listed below. (Do not repeat above name.) Name (Please Print) 1 2 3 |-- 5 Relationship Sex Date of Birth Month Day Year Age I I I hereby apply to Academy Life Insurance Company. I understand my coverage will take effect on the Effective Dale shown in the Policy Schedule. I further understand that injury or sickness suffered before I he Effective Date wil be covered after the Policy has been in foice two years, and that new conditions aie covered immediately. Policy form H-603 Academy Life Insurance Company Administrative Offices: Valley Forge, Pa. 19481 Licensed in the State of West Virginia

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