The Ogden Standard-Examiner from Ogden, Utah on October 3, 1971 · Page 106
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The Ogden Standard-Examiner from Ogden, Utah · Page 106

Ogden, Utah
Issue Date:
Sunday, October 3, 1971
Page 106
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^ COMPLETE AND MAIL THIS FORM TO: NATIONAL HOME Valley Forge, Pa. 19481 mmOmmm "newt ENROLLMENT FORM ; ooooococc Official Enrollment Form for the Hospitalization Indemnity Plan NATIONAL HOME LIFE ASSURANCE COMPANY An Old Line Legal Reserve Company of St. Louis, Missouri ADMINISTRATIVE OFFICE: VALLEY FORGE, PENNSYLVANIA PleMe Prlnl NAME MRS. MISS First ADDRESS cmr DATE OF BIRTH Month Day OCCUPATION Middle Inlt al Street or RDS STATE Year AGE ^~ ZIP SE List all dependents to be covered under this Plan. (DO NOT include name that appears above, necessary.) . NAME (Please Print) 1 2 3 4 5 RELATIONSHIP SEX OOOCOOWjC mm. 2-1456*01 asi XMale C Female o Jse separate sheet if DATE OF BIRTH Month Da i / 1 Year ... | _. .. t AGE Check r,*r* II you wan) Conngt tar Yout Children. Chacfc h»n If you wanl Covtrag* tor Your Children and Ualsmlty Btneiits. I hereby enroll in National Home's Hospital Plan and am enclosing the first month's premium to cover mysel! and ail other Covered Members listed above. To the best of my knowledge and belief neither i nor any person listed above has been refused or had cancelled any health, hospital or life insurance coverage due to reasons of health. I understand that this Policy will become effective when Issued and thai pre-existing conditions wilt be covered after two years. Signature X r>ato NHA-10 NH10-669EP5 (600) Cat. \V ' MVlLTHis'ENROLLMENTFORM'BEFORE MIDNIGHT,' ODT.'lV, 1971' H1438 Limited Enrollment Ends Soon Your low Introductory Premium cover* .your entire family for the ffrat month. I ' 2-1456-frOl I USE THIS COUPON IF YOU ARE I 65 OR OVER j Please send me complete information ! on your special health plan lor folks I 65 or over. 1 understand there Is no i obligation ... no cost. . . and no | salesman or agent will call. i Please 1 Print NAME - 1 ADDRESS- CITY STATE. AGE_ _DATE OF B1RTH- _ZIP_ HOME r HEALTH >*™?:'"b PLAN,. National Home Life Assurance Company a division of National Liberty Corporal!on Governor William W. Scrinton, Chairman of the Board Adtn. Of flees: Valley Forge, Pennsylvania! This plan is underwritten by National Home life Assurance Company, an old line legal reserve company of ..St'. Louis, Missouri. National Home is licensed by your state and carries full legal reserves for the protection of all policyowners. FILL OUT THE ENROLLMENT FORM AND RETURN TODAY

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