Stockminster Assurance Society Limited 44 High Street Stockminster sri 1aa Tel: 0022 3334444 life proposal form

You must answer the following questions to the best of your knowledge and belief. Failure to do so may result in part or all of the benefits due under any policy issued as a result of this proposal being cancelled. If you are in any doubt about the relevance of certain facts you should disclose them. Each question should be answered fully In your own handwriting. 1.Name (in full)............................Marital status............................ Address............................ Occupation............................Age next birthday............................ Born at ............................on the............................day of........................................................ 2. Type of policy................With or Without Profits .................Sum to be assured £ ................ (a) Payable at death only............................ (b) Payable at end of given term of years or previous death……… State terms of years............ Premiums to be payable annually or monthly?................. Number of years payable ................ 3. Has any previous proposal on your life been made to this Society? .......... Policy No............ Has any proposal on your life been declined, postponed, withdrawn, or accepted on special terms by this or any other Company?............................ It is important that the name of the Company, the date and full particulars be given in every case. 4. Are you ever likely to: If YES please give details: a) fly other than as a fare paying passenger? ........................... b) be engaged in a hazardous occupation or activity? ............................ c) live or work abroad? ........................... 5. Names and addresses of all Doctors you have consulted within the last five year with dates and reasons for consultation: Name and address of Doctor Reason for consultation Date

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6. Please state: Height.............ft...................in Weight (in indoor clothes)................st............... lb 7. Have you smoked cigarettes in the last 12 months?..........If YES, how many per day?........... 8. Do you consume alcohol?.................................

Average daily consumption........................... Are you now in thoroughly sound health?............................

Declaration

I hereby declare that the above statements are true and complete, and I agree that these statements, together with the j statements to be made to the Medical Examiner if a medical examination should be required, shall be the basis of the contract between me and the Society. I consent to the Society seeking medical information from any doctor who at any time has attended me, and making inquiries of any Life Assurance Company to which I have at any time made a proposal for life assurance, and I authorise the giving of such information. Date............................ Signature of Proposer............................

Section M. Opposites and synonyms

Find opposites for the words highlighted in the following passage and synonyms for the words in italics.