Alton Evening Telegraph from Alton, Illinois on September 1, 1972 · Page 29
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Alton Evening Telegraph from Alton, Illinois · Page 29

Alton, Illinois
Issue Date:
Friday, September 1, 1972
Page 29
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Page 29 article text (OCR)

ENROLLMENT FORM ^ Official Enrollment Form for the Hospitalization Indemnity Plan NATIONAL HOME LIFE ASSURANCE COMPANY An Old Line Legal Reserve Company of St. Louis, Missouri ADMINISTRATIVE OFFICES: VALLEY FORGE, PENNSYLVANIA (Please Print) 1-2408-0-11 MR. Name MRS. MISS Address . . l-irst M kill It- Inilul I.HSI Street or HI) # State ...Zip ----- Date of Birth. Sex Male Female Month Day Year Occupation .. . . . . . List all dependents to be covered under this Plan: (DO NOT include name that appears above. Use separate sheet if necessary.) •NAME (Please Print) 1 2 3 4 5 RELATIONSHIP SEX DATE OF BIRTH MONTH DAY YEAR AGE Q Check here if you want Coverage for Your Children. Q Check here if you want Coverage for Your Children and Maternity Benefits. I hereby enroll in National Home's Hospital Plan and am enclosing the first month's premium to cover myself and all 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 that pre-existing conditions will be covered after two years. Signature X NHA-10 Date_. NH12-669EP3 (600) H2286IL-R DON'T DELAY-COMPLETE AND MAIL THIS ENROLLMENT FORM TODAY! Dear Friend: I've made a point of getting to know the folks at National Home. And you won't find more decent, friendly people to deal with. I've seen the way they handle claims, too—quickly and efficiently. Believe me, when you need them, they'll be there to help you. HOW TO GET YOUR POLICY •J _ Complete this brief Enrollment Form. 2. Fold and tear along dotted line. O Enclose Form with 250 In reply envelope inside **• and mail to NATIONAL HOME, Valley Forge, Pa. 19481 • Copyright 1972, National Liberty Corporation NAL HOME HEALTH PLAN rM National Home Life AMuranoe Company a member of the National Liberty Group Adm. Offices: Valley Forge, Pennsylvania This policy is underwritten by National Home Life Assurance Company, an old line legal reserve company of St. Louis Missouri. National Home is licensed in 46 states, including Illinois, and carries full legal reserves for the protection of all policyowners. Established 10aO-Over BO Teara of Reliable Service

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