This section is from the book "Hill's Manual Of Social And Business Forms: A Guide To Correct Writing", by Thos. E. Hill. Also available from Amazon: Hill's Manual Of Social And Business Forms: The How-To-Do-Everything Book Of Victorian America.
To the Home Life Insurance Company, Brooklyn and New York.
The applicant is expected and required to answer ail the following questions definitely and fully. Notice to applicants. It is desirable that the answer be written by the hand of the applicant; if written by the agent, it will be at the request of and as the amanuensis of the applicant.
1. For whose benefit is the insurance to be effected?
2. Whose life to be insured?
3. Amount of assurance?
4. How do you wish to pay the premium?
5. When and where was the party to be insured born?
6. Is the party in good health, and free from any symptom of disease?
7. Is the party whose life is to be insured married?
8. Has the party been vaccinated, or had the small-pox, or varioloid?
9. Are the habits of the party uniformly and strictly sober and temperate?
10. Has the party ever been addicted to the excessive or intemperate use of any alcoholic stimulants or opium? Does the party use, habitually, intoxicating drinks as a beverage? Does the party practice any bad or vicious habit that tends to the shortening of life?
11. What employments has the party been engaged in? Has the health of the party suffered thereby? Has the party been engaged or employed in the manufacture or sale of intoxicating liquors? If so, in what way and when?
12. Is the party now deaf, dumb, blind, or crippled in any way.
13 Has the party ever had any of the following diseases, or any symptoms thereof? (Here follows a long list of well-known, ordinary maladies.) If the party has had one or more of these diseases, please state particularly which.
14. Has the party had inflammatory rheumatism? If so, when and how often?
15. Has the party ever had disease of any vital organ? If so, what was it, and when?
16. Is the party subject to dyspepsia, diarrhoea, or vertigo?
17. Has the party ever had an habitual cough? Has he ever spit blood?
18. Has the party ever met with any severe personal injury? If so, what?
19. Has the party had, during the past ten years, any sickness or disease? If so, state the particulars of each and every such sickness or disease, and the name of each and every physician or physicians who prescribed or who were consulted?
20. Have the ancestors of the party generally reached old age?
21. Have the parents, uncles, aunts, brothers or sisters of the party been, or are any of them now afflicted with insanity, fits, cancer, dropsy, or chronic disease of brain, lungs, heart, kidneys, or liver? If so, state explicitly how many and who?
22. Are the parents of the party living?
23. Are the parents of the party dead?
24. How many brothers has the party had? How many sisters? How many are living, and their names? At what ages? What is the state of their health respectively? How many have died, and their names? At what age? Of what disease did they die?
25. Has the party employed or consulted any physician for self or family? Please answer this, Yes or no. If Yes, give name or names of each and every such physician, and residence.
27. What amount is now assured on the life of the party, and in what company or companies?
28. Has application ever been made to this or any other company for insurance on the life of the party, which was not granted? If so, what company, when, and for what reason?
29. Have you read the " Notice to Applicants'" at the head of this page, and have you duly considered your answers to all the foregoing questions? Do they definitely express what you intend to say, and are you aware that any untrue, evasive or fraudulent answer to the above queries, or any suppression or misstatement of facts in these answers in regard to the health, habits, or circumstances of the party, or of the family relations of the party, will vitiate the policy, and forfeit all payments thereon?
[The party insured here affirms that he has truly answered the above, which affirmation is duly attested by a competent witness. J
The foregoing questions being answered to the satisfaction of the company, a policy is issued to the party insured in the following form:
HOME LIFE INSURANCE COMPANY,
OF BROOKLYN AND NEW YORK,
Age, 49 Years.
In consideration of the representations and agreements contained in the application therefor, and of the payment of two-thirds of the amount premium of Eighty Dollars, and the interest on one-third of the said annual premium (which third is a loan secured by this policy, to be liquidated as hereinafter stated), by Edward G. Martell,
Does assure the life of Edward G. Martell, of Fleming, in the county of Cox, State of New Jersey, in the sum of Two Thousand Dollars for the term of life, with participation in profits. And the said Home Life Insurance Company does hereby promise and agree to and with the said Edward G. Martell to pay the sum assured (less the balance of the year's premium, if any, and any indebtedness to the company on account of this contract, or for any loan made on said policy) at its office in this city, to his wife, Mary Louise Martell, within sixty days after due notice and satisfactory proof of death, and interest, in accordance with the terms of this contract.
Provided always, and it is hereby declared to be the true intent and meaning of this policy, and the same is granted by this company, and accepted by the said Edward G. Martell upon these express conditions, that if the statements made by or for him, contained in the application bearing date the tenth day of January, 1881, upon the faith of which this policy is made (which statements he makes his own, and warrants to be full, correct and true), or any part thereof, shall be found untrue, incomplete or deceptive in any respect; or in case the said Edward G. Martell shall not actually pay the first premium as aforesaid, before the delivery of this policy, and while the said Edward G. Martell is in good health, or shall not pay, or cause to be paid to this company, at its office in the city of New York on or before the seventeenth day of January, at 12 o'clock, noon, in each and every year during the continuance of this policy, the said two-thirds of the annual premium of eighty dollars, to wit, the sum of fifty-three dollars and thirty-three cents, and annually in advance during the continuance of this policy, the interest on one-third of the annual premiums which may have loaned to the assured from year to year, or so much thereof as may remain unpaid; or in case the said Edward G. Martell shall not pay, or cause to be paid, any note or notes which may be given to and received by said company, in part payment of any premium, on the day or days when the same shall become due;
Or in case the said Edward G. Martell shall, without the written consent of this company, previously obtained, engage as mariner, engineer, fireman, conductor, agent, messenger, laborer or servant in any capacity, in service on any sea, sound, inlet, river, lake or railroad, or in the manufacture of any explosive substance, or of any article of which any explosive substance or compound forms a component part, or in submarine operations or mining, or shall enter upon or engage in any aerial voyage, or in any military or naval service whatsoever (the militia not in actual service excepted);
Or in case the said Edward G. Martell shall die in consequence of a duel, or of the violation of law, then, and in every such case, the said company shall not be liable for the payment of the sum assured, or any part thereof, and this policy shall cease, and be null, void and of no effect.
[Provisions restricting the assured to moderation in living, avoiding hurtful business and non-payment of premiums, etc., are omitted.]
In "Witness Whereof, The Home Life Insurance Company has, by its president and secretary, signed and delivered this contract at the city of New York, in the State of New York, this seventeenth day of January, one thousand eight hundred and eighty-one.
---------------, Secretary. ---------------, President.
Marginal Note. - Notice to the Holder of this Policy: No agent of this company is authorized or permitted to waive, alter or change any of the conditions of this policy, or agree to any terms not herein distinctly stated, nor to collect or receive any premiums which may become due and payable under it, without producing and delivering to the insured a receipt for said premium, signed by the president or secretary of this company.