PROPOSAL FOR LIFE INSURANCE

If any change has taken place in the Name it should be stated.

Proof should

be furnished in

order that the

Name, Residence, Profes

sion or Occupation of the

Person whose Life is to
be Assured?

Place and Date of Birth?

Policy may be Has the Life been proposed

Indisputable.

If no Medical
Attendant, a
second Private
Reference

should be
named.

This question need only be answered when the Proposal is on the Life of another

person.

to any other Office? If
so, name the Office and
the result of the Proposal

Name and Residence of
usual Medical Attendant;
how long has he known
you?

Name and Residence of any
other Medical Gentleman
consulted within the past
seven years?

Name and Residence of an
intimate Private Friend;
how long has he known
you?

Sum to be assured?

With or without Profits?
Term for which Assurance
is required?

Name, Residence, and Oc-
cupation of the Person in
whose favour the Policy is
to be granted?

I declare the above statements are true; that the Private and Medical Referees named are competent to give information as to past and present state of health and habits of life; and I agree that such Statements, together with those made or to be made to the Medical Officers of the Society and signed by me, shall be the basis of the proposed contract of Assurance.

The Policy, on the age being admitted, will be indisputable except on the ground of fraud.

Sum Assured £

WHEREAS

FORM OF LIFE POLICY

No.

Premium £

(hereinafter called The Life Assured), whose age is admitted not to exceed

years, has this day paid to the ASSURANCE SOCIETY the sum of

as a first Premium on this Policy and

the like Premium is to be paid on the same day in every future year during the whole survivorship of The Life Assured in order to keep this Policy on foot :

Now these Presents witness, That on the death of The Life Assured and on due proof given of the death and of title, the Society will pay to the executors, administrators, or assigns, of The Life Assured the sum of pounds, together

with any BONUS which according to the provisions of the Deed of Settlement of the Society may at the time of such death be attached to this Policy:

Provided That this Policy is granted upon the following conditions, that is to say :

(1) That payment of every Premium, which is to be paid as above

mentioned, be made within Thirty Days from the day fixed for payment thereof; and if so made, this Policy shall remain in force notwithstanding the death of The Life Assured during such thirty days.

(2) That, if The Life Assured commit suicide within one year from the date of this Policy, all money which would otherwise have become payable for the benefit of his estate under this Policy shall be forfeited and belong to the Society; but this condition shall not prejudice the interest in such money of any Assignee for value.

Provided also That the Society's Assurance Fund for the time being, and the Proprietors' Fund on the first day of (which then amounted to the sum of £

), and so much

of the Capital of the Society, held in Shares by the Proprietors and others, as on the said first day of had not been paid up

or according to the provisions of the Deed of Settlement been considered as paid up (such Proprietors' Fund and Capital amounting together to the sum of One Million Pounds Sterling), shall alone be liable to any claim or demand in respect of this Policy; and no

Director signing this Policy, nor any other Proprietor, shall be liable to any claim or demand in respect thereof beyond the unpaid portion of the Capital held by him. And as to the Proprietors' Fund, nothing herein contained is to be construed to give to any person entitled to the benefit of this Policy any charge or claim on any accumulation thereof made, or to be made, after the thirty-first day of

In witness whereof We, Three of the Directors of the said Society, have hereunto set our hands this

One thousand eight hundred and

Examined

day of

Entered

NOTICE

All Notices of Assignment of the Policy must be sent direct to Street, London, the principal place of business of the Society. No Agent of the Society is authorised, under any circumstances whatever, to receive, acknowledge, or transmit such Notice.

GUARANTEE OF SURRENDER VALUE

The within written Policy will acquire a Surrender Value so soon as three full annual Premiums have been paid, and the Society then guarantees the following sums as the Surrender Value, namely:(1) One-third of so much of the Premiums received as would represent ordinary Premiums on the same Policy according to the true age at the date of issue thereof.

(2) The full Cash Value calculated according to the published Bonus Table of the Profits (if any) attached to the Policy at the time of surrender.

PROTECTION AGAINST FORFEITURE FOR NON-PAYMENT OF PREMIUMS IN CERTAIN CASES AND FOR A LIMITED TIME

When a Policy has a Surrender Value, then, notwithstanding an omission to pay any subsequent Premium or Premiums, the Policy will remain in force unless and until the Surrender Value of the Policy, as at the date when the first unpaid Premium is payable, becomes exceeded by the total of the amount due in respect of Premiums, and in respect of any loan made on the Policy by the Society and of the accumulated compound interest with half-yearly rests on the amount of Premiums

and loan (if any) at the rate for the time being charged on loans made by the Society on the security of their Policies.

The Premium or Premiums due, if paid with accumulated compound interest at the before-mentioned rate while the Policy remains in force under this Provision, will be accepted by the Society.

Own Life.

Age Proved.

£

FORM OF MARINE POLICY

BE IT KNOWN THAT

as well in
own Name, as for and in the Name and
Names of all and every other Person or Persons to whom
the same doth, may, or shall appertain in part or in all, doth
make assurance, and cause
and them and
every of them, to be insured, lost or not lost, at and from

upon any kind of Goods and Merchandises, and also upon the Body, Tackle, Apparel, Ordnance, Munition, Artillery, Boat and other Furniture, of and in the good Ship or Vessel called the

whereof is Master, under God, for this present voyage,

or whosoever else shall go for Master in the said Ship, or by whatsoever other Name or Names the said Ship or the Master thereof is or shall be named or called, beginning the Adventure upon the said Goods and Merchandises from the loading thereof aboard the said Ship

upon the said Ship, &c.

and shall so continue and endure, during her Abode there, upon the said Ship, &c., and further, until the said Ship, with all her Ordnance, Tackle, Apparel, &c., and Goods and Merchandises whatsoever, shall be arrived at

upon the said Ship, &c., until she hath moored at Anchor Twenty-four Hours in good Safety, and upon the Goods and Merchandises, until the same be there discharged and safely landed; and it shall be lawful for the said Ship, &c., in this Voyage to proceed and sail to and touch and stay at any Ports or Places whatsoever

without Prejudice to this Insurance. The said Ship, &c., Goods and Merchandises, &c., for so much as concerns the Assured, by Agreement between the Assured and Assurers in this Policy, are and shall be valued at

Touching the Adventures and Perils which we the Assurers are contented to bear and do take upon us in this Voyage, they are, of the Seas, Men-of-War, Fire, Enemies, Pirates, Rovers, Thieves, Jettisons, Letters of Mart and Countermart, Surprisals, Takings at Sea, Arrests,