62
THE NEW ZEALAND GAZETTE.

Questions to be Answered.
No. of
Question.
Questions to Proposer.
No. of
Answer.
Answers by Proposer.
1 Are you, or have you been 1
married?
2 Are your Father and Mother
alive? If alive, state their
present ages; and if dead,
state their ages at death, and
the cause of death.
3 Have you, or have you had, any
Brothers or Sisters? If so,
state the present age of each
of those now living, and the
age at death of each of those
who are dead.
4 How long have you followed
your present trade or occupa-
tion?
5 Have you ever followed any 5
other trade or occupation than
that which you now follow?
If so, state the nature of each
other trade or occupation
which you have followed, and
the time during which you
followed each.
6 Have you been out of employ-
ment or absent from work or
business on account of ill
health during the last two
years, reckoning back from
the date of this proposal? If
so, state how often you have
been out of employment or
absent from work or business,
and for how long on each
occasion?
7 Are you a member of any 7
Friendly or Benefit Society,
or of any Sick Club or Burial
Club? If so, name the Society
or Club to which you belong,
and state how long you have
belonged to it.
8 Have you ever proposed to in- 8
sure your life with any In-
surance Office? If so, state
the name of each office to
which you have made such
proposal, and state whether
your proposals have been
accepted or rejected, and
whether you have in any case
been charged with more than
the ordinary rate of premium.
9 Are you now, and have you 9
always been, of sober and
temperate habits?
10 Have you been vaccinated? 10
11 Are you now, and have you 11
generally been in good health?
2
Father
Mother
Present Age,
if living.
Age at Death,
if dead.
Present Age,
if alive.
Age at Death,
if dead.
Cause of Death.
Questions to Proposer.
12 What countries have you lived 12
in, and for how long?
13 Have you ever sustained any 13
serious personal injury,
through an accident, or in any
other way? If so, state the
circumstances, and the nature
and extent of the injury.
14 Have you ever suffered from 14
Gout, Rheumatism, or Rheu-
matic Fever, from Small Pox,
from Asthma, Spitting of
Blood, or Palpitation of the
Heart; or from Palsy or Fit
of any kind, or from Delirium
Tremens, or from Rupture or
Stricture? If so, state when
you have so suffered.
15 Have you been attended by any 15
medical men, or received
advice or medicine from any
medical men, within the last
two years, reckoning back
from the date of this proposal?
If so, state the names of such
medical men, and the nature
of the illness for which they
attended or treated you.
16 Have any of your relations 16
suffered from any Scrofulous
Affection, or from Asthma,
Consumption, or Insanity?

Form of Declaration.
WHEN this Proposal Form has been filled up, the
following Declaration must be signed by the Proposer
in the presence of a Postmaster or other Officer duly
appointed for the purpose:—

I do hereby declare that the foregoing statements made by me
are true to the best of my knowledge and belief, and that I have
not withheld or concealed any circumstance with regard to
which information has been required from me. I agree that
the foregoing statements and those which I shall make to the
medical referee of the Government Annuities Commissioner
shall be the basis of the proposed contract for an insurance on
my life; and that if it shall hereafter appear that I have wilfully
made any untrue statement, or have fraudulently concealed any
circumstance which I ought to have made known, then all the
premiums which shall have been paid under the said contract
shall be forfeited, and the contract rendered absolutely null and
void.

(Signature of Proposer.)

Statement by Postmaster or other Officer.
Postmaster's Statement.

I certify that I read over and explained the above declaration
to the Proposer in this case, and that the Proposer's signature
was affixed in my presence.

(Signature.)

day of 18 .

Proposer to be referred to Medical Practitioner.
4. The Postmaster or other Officer, after examina-
tion of the said proposal, and after inquiry has been
made of the persons to whom the Proposer refers,
shall, if he think fit, direct the Proposer to present
himself for medical examination by a legally qualified
Medical Practitioner.

Medical Examiner to report to Commissioner.
5. The Medical Examiner, after examination of the
Proposer, shall make his report on a Proposal Form,
a copy of which is attached to the instructions to