554
THE NEW ZEALAND GAZETTE.

Wellington, Esquire, has been appointed Government Annuities
Commissioner for the purposes of the said Acts: And whereas
the said Commissioner is authorized to execute contracts for
the insurance of lives: And whereas
herein-
after called "the Assured," has contracted with the said Commis-
sioner for an Insurance of the sum of £
payable at
death, or the attainment of a specified age, and has deposited
with him a proposal and declaration, dated the
day of
one thousand eight hundred and
and signed
by him as the basis of the contract for such Insurance, and has
also made certain statements and a declaration, dated the
day of one thousand eight hundred and to a Medical
Examiner: And whereas the said Assured has paid to the said
Commissioner the sum of £
as the first annual premium
for such Insurance: - Now it is hereby declared that if the said
Assured shall die at any time within the term of twelve
calendar months from this date, then the said Commissioner shall,
pursuant to the said Acts, be subject and liable to the
payment unto the executors, administrators, or assigns of the
said Assured, immediately after satisfactory proof of his death
shall have been received by the said Commissioner, of the sum
of £
And further, that if the said Assured shall
survive the said term of twelve calendar months, and shall, on or
before the
day of
next ensuing, and on or before
the
day of
in every succeeding year, until the
said Assured shall attain the age of [fifty, fifty-five, sixty, or
sixty-five years, as the case may be], unless he shall sooner die,
duly pay the like amount of premium, then the said Commis-
sioner shall, pursuant to the said Acts, be subject and liable
to the payment to the said Assured when and so soon as he
shall have attained the age of
years, unless he shall
sooner die; and, in case he shall sooner die, then unto the
executors, administrators, or assigns, of the said Assured, im-
mediately after satisfactory proof of his death shall have been
received by the said Commissioner, of the sum of £
But this contract is made subject to the condition that it
shall be void, and all the payments made by or on behalf of
the said Assured under it shall be forfeited, in any of the fol-
lowing cases:-
1st. If the statements of the Proposer, as set forth in the
proposal, or of the person or persons examined by the
Medical Examiner, as set forth in the medical examina-
tion, or any of such statements respectively, be untrue,
or if any person whose life is assured has wilfully with-
held any information required of him.
2nd. On default of payment of the annual or other
periodical payment to be made thereunder.
3rd. If the person, or any of the persons upon the con-
tingency of whose life or lives the particular transaction
is to depend, shall go or travel beyond the limits allowed
by the Regulations without the leave of the said Com-
missioner.
4th. If the Assured shall adopt any trade or occupation
declared by the said Commissioner to be hazardous
without the leave of the said Commissioner.
5th. If the Assured shall die by his own hand, or by
duelling, within twelve months, or by the hands of
justice.
6th. On breach, non-observance, or non-performance, in
any other respect, of the Acts or Regulations for the
time being in force affecting the same.
In witness whereof the said Commissioner hath here-
unto set his hand and seal this
day of
one thousand eight hundred and
Signed, sealed, and delivered
by the said Commissioner,
in the presence of

Form of Contract for Insurance of a Sum of Money payable on
the Death of either of Two Lives.

WHEREAS under the provisions of "The Government Annuities
Act, 1869," and "The New Zealand Government Insurance
and Annuities Act, 1870," William Gisborne, of the City of
Wellington, Esquire, has been appointed Government Annuities
Commissioner for the purposes of the said Acts: And whereas
the said Commissioner is authorized to execute contracts for the
insurance of lives: And whereas
of
herein-
after called "the Assured," has contracted with the said Commis-
sioner for an Insurance of the sum of £ payable on the
death of either of two lives, and has deposited with him a
proposal and declaration dated the
day of
one
thousand eight hundred and
and signed by him as the
basis of the contract for such Insurance, and has also made
certain statements and a declaration dated the
day of
one thousand eight hundred and to a Medical
Examiner: And whereas the Assured have paid to the said
Commissioner the sum of £ as the first annual premium
for such Insurance: - Now it is hereby declared, that if either of
the said Assured shall die at any time within the term of twelve
calendar months from this date, then the said Commissioner shall,
pursuant to the said Acts, be subject and liable to the payment
to the survivor of them, or to the executors, administrators, or
of such survivor, immediately after satisfactory proof of the first-
mentioned death shall have been received by the said Commis-
sioner, of the sum of £
: And further, that if
both of the said Assured shall survive the said term of twelve
calendar months, and shall, on or before the
day of
next ensuing, and on or before the
day of
in every succeeding year, until either of the said Assured
shall die, duly pay the like amount of premium, then the said
Commissioner shall, pursuant to the said Acts, be subject and
liable to the payment unto the survivor of them the said
Assured, or unto the executors, administrators, or assigns of such
survivor, immediately after satisfactory proof of the first-
mentioned death shall have been received by the said Commis-
sioner, of the sum of £
But this contract is made subject to the condition that it
shall be void, and all the payments made by or on behalf of
the said Assured under it shall be forfeited in any of the following
cases:-
1st. If the statements of the Proposer, as set forth in the
proposal, or of the person or persons examined by the
Medical Examiner, as set forth in the medical examina-
tion, or any of such statements respectively, be untrue,
or if any person whose life is assured has wilfully with-
held any information required of him.
2nd. On default of payment of the annual or other
periodical payment to be made thereunder.
3rd. If the person, or any of the persons upon the con-
tingency of whose life or lives the particular transaction
is to depend, shall go or travel beyond the limits allowed
by the Regulations without the leave of the said Com-
missioner.
4th. If the Assured shall adopt any trade or occupation
declared by the said Commissioner to be hazardous
without the leave of the said Commissioner.
5th. If the Assured shall die by his own hand, or by
duelling, within twelve months, or by the hands of
justice.
6th. On breach, non-observance, or non-performance, in
any other respect, of the Acts or Regulations for the time
being in force affecting the same.
In witness whereof the said Commissioner hath here-
unto set his hand and seal this
day of
one thousand eight hundred and
Signed, sealed, and delivered
by the said Commissioner,
in the presence of

Form of Contract for Insurance of a Sum of Money at
Death of One Life if Another be then Living.

WHEREAS under the provisions of "The Government Annuities
Act, 1869," and "The New Zealand Government Insurance and
Annuities Act, 1870," William Gisborne, of the City of Wel-
lington, Esquire, has been appointed Government Annuities
Commissioner for the purposes of the said Acts: And whereas
the said Commissioner is authorized to execute contracts for
the insurance of lives: And whereas
of
herein-
after called "the Assured," has contracted with the said Com-
missioner for an Insurance of the sum of £
on his own life,
conditioned as hereinafter mentioned, and has deposited with
him a proposal and declaration dated the
day of
one thousand eight hundred and
and
signed by him as the basis of the contract for such Insurance:
And whereas certain statements and declarations, dated the
day of
one thousand eight hundred and
have been made to a Medical Examiner in connection with such
proposal: And whereas the said Assured has paid to the said
Commissioner the sum of £
as the first annual
premium for such Insurance: - Now it is hereby declared,
that if the said Assured shall die at any time within
the term of twelve calendar months from this date, then
the said Commissioner shall, pursuant to the said Acts,
be subject and liable to the payment to the executors,
administrators, or assigns of the said Assured, immediately
after satisfactory proof of his death shall have been received by
the said Commissioner, of the sum of £
provided
of
a person named in the said proposal, shall then
be living: And further, that if the said Assured shall survive
the said term of twelve calendar months, and shall, on or
before the
day of
next ensuing, and on or
before the
day of
in every succeeding year
during his life, duly pay to the said Commissioner the like amount
of premium, then the said Commissioner shall, pursuant to the
said Acts, be subject and liable to the payment unto the executors,
administrators, or assigns of the said Assured, immediately
after satisfactory proof of his death shall have been received
by the said Commissioner, of the sum of £
provided
the said
shall then be living.
But this contract is made subject to the condition that it shall
be void, and all the payments made by or on behalf of the said