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N. B.-Answers to the following questions must be elicited and recorded by a regularly appointed Examiner of the Company, with no one present but the Examiner and the person examined.

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13. A. Have you ever had Inflammatory or Articular Rheumatism? n. If so, state the

A.

14.

number of attacks. o. The duration of each attack. D. In what pears, and parts affected.
Have you undergone any Surgical Operation, or have you ever had disease
of bones or joints, spinal curvature, or any bodily malformation?

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15.

Has sugar, albumin or casts ever been found in your urine?

16.

Are you ruptured? B. If so, do you wear a truss constantly except when in bed?

A.

17. A. Are you drawing or have you ever applied for a pension? B. If so,
for what disability?

A.

18.

Have you had since childhood any chronic or constitutional disease or severe in-
Jury not fully set forth above?

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II-Continued

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REVIEW THIS PAPER CAREFULLY BEFORE SIGNING. DO NOT USE DISHES OR DITTO MARKS. WHEN COMPLETED HAND TO AGENT. I certify that the above is a record of a careful examination of the person described in and whose signature is affixed to the foregoing declarations, and that the examination was made

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N. B.-THIS EXAMINATION MUST BEAR DATE OF DAY WHEN ACTUALLY
MADE, AND UNDER NO CIRCUMSTANCES ANY OTHER.

If not a regularly appointed Examiner of the Company, state where graduated..

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ADDITIONAL HEMARES.-State anything discovered by you which may influence the character of the

isk, and which is not set forth fally in the foregoing answers.

II-Continued

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Read these Instructions as they are Imperative and must not be deviated from in any manner.

Note I. The answer to Question 6 must be definite and convey a clear idea as to the past and present habits of the Insured in the use of stimulants. Such answers as "moderately." "temperately," or "not to excess," and the like, will not be accepted.

If there is a history of over-indulgence or a free use of stimulants, a full explanation will
be required over the signature of the lasured.

Note II. Full details should Recompany the application where Insured is engaged or
expects to engage in any bazardous employment, such as a bazardous position on a railroad,
electrical employment where the voltage is in excess of 250 alternating current, auto racing in
scheduled races, travelling salesman for liquors, mining, seafaring, serial navigation, handling
explosives, etc., or any occupation or amusement which would render the risk a hazardous one.

Note III. If a member of Insured's family bas tuberculosis or within two years has died
of tuberculosis, or be is associated closely at his place of business with persons suffering from
tuberculosis, see that the application contains full particulars as to relationship and as to pre-
cautions to prevent infection.

Note IV. The speelfe disease must be stated. Indefinite terms mast not be used in
recording causes of death of Insured's family, or in giving a history of previous illnesses
lasured may have had, e. g., colic, billousness, indigestion, etc. In such cases the application
abould show whether or not nephritic or hepatic colle or calculus or appendicitis, ete., was one-
pected. Such Indefinite terms as abscess, injury, grippe, cold, catarrb, neurastbenta, etc., etc.,
will not be accepted without a detailed explanation.

VOUCHER.

Fees for Medical Examinations are paid only through
the Home Office at Milwaukee. This Voucher must be filled
out by the Medical Examiner at the time of the examina-
tion, detached and forwarded at once with any additional
Information which in his opinion may have a bearing upon
the risk. See Notes IX and X

At the close of each quarter a Company check for amount
due for examinations shown by these vouchers will be for-
which may be cashed atlocal beak when property
dorsed by the Medical Examiner.
Address, Medieal Department,
MUTUAL LIFE Ins. Co..

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Maturity &
Endokoment

John Doe

Hartford

Hartford.County of...

Wife

Dollars

......the Insured,

State of...

Connecticut........

during the continerance of this contract and before its maturity as an endowment.

First

day of...

The Insured, if living on the.......
February... .19..39.
and if the premiums required under this contract shall have been paid, shall receive the amount of this
insurance.

This contract is issued in consideration of the signed application for this insurance which is made a part
hereof and copy of which is attached hereto, and of the premium of

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When Bapable/

Where Papahle

Bate Ellectibe

Incontestability

Four Hundred Twenty-eight

Annually

or a Secretary and countersigned by an authorized

(The annual premium includes a premium of $..
benefits as set forth on the third page hereof)

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The first such payment shall be made on the delivery of this contract, and a like payment on or before the..

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First
O

in each year until premiums for..

Twenty

February

full years shall have been paid or until the prior death of the Insured, but no such payment will be required during permanent total disability after receipt by the Company of due proof thereof

remiums shall be paid in advance at the Home Office or to an authorized agent of the Company. This insurance shall be effective from..... February 1st.19.19. The Insurance Years, and all subsequent provisions for Cash Loans, Cash Values, Paid-up and Automatic Term Insurance are computed from that date.

This contract shall be incontestable after one year from date of issue, except for non-payment of premiums. It is free from conditions as to residence, occupation, travel or place of death, including military or naval service unless such service shall be restricted by indorsement hereon at the time of issuance of the contract.

This contract is subject to the privileges and conditions recited on the subsequent pages hereof. Witness Whereof THE 4NSURANCE COMPANY has caused this instrument to be signed by its President and a Secretary, at First day of........

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20 YEAR ENDOWMENT. PREMIUMS PAYABLE FOR 20 YEARS. NON-PARTICIPATING.

IN EVENT OF PERMANENT TOTAL DISABILITY PREMIUMS WAIVED AND MONTHLY INCOME PAYABLE WITHOUT
DEDUCTION FROM INSURANCE.

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