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To be answered by the proposed insured. If any of these questions are answered “Yes”, give complete details.
Life insurance in Force and Pending with All Companies on Proposed Insured, including Business Insurance named in any of the following Sections 1, 2 (if none, skip this section).
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I hereby authorize any licensed Physician, Medical Practitioner, Hospital, Clinic or any other medically related facility, Insurance Companies, Medical information Bureau or any other organization,institution or person that has any records or knowledge of my health, to give RF&G Life Insurance Company Limited or its Reinsurers any such information. I further consent to undergo an Electrocardiogram, X‐ray, Blood test (for Diabetes, AIDS, etc.) or any other test considered necessary by RF&G Life Insurance Company Limited or its Reinsurers. I additionally authorize RF&G Life Insurance Company Limited or its Reinsurers to obtain a Consumer Report containing personal information and financial information in connection with this application. I also authorize RF&G Life Insurance Company Limited or Reinsurers to provide other insurance companies with data on my life from their files. To facilitate rapid presentation of all such information, I authorize all the above mentioned sources, to give such records or knowledge to any agency employed by RF&G Life Insurance Company Limited to collect and transit such information. A photocopy of this authorization shall be as valid as the original. I have read the conditional insurance agreement and understand it.
I/we, the undersigned, do hereby declare that the above‐written particulars are fully and truly stated; and I do hereby agree that this declaration shall be basis of the contract between me/us and RF&G LIFE INSURANCE COMPANY LIMITED, and that, if any untrue statement has been made, or information necessary to be made known to the Company has been withheld in Part 1 and/or Part 2 of the Application and Declaration the Assurance shall be absolutely null and void; and that my acceptance of any Policy issued by reason of the Application and Declaration shall constitute ratification of any corrections and amendments made by the Company and noted in the space “Corrections and Amendments” (in Section 9). I hereby confirm that all expenses for medical and laboratory requirements requested by RF&G Life Insurance Company Limited will be fully paid by me if I choose not to accept the term and conditions of the approved coverage. Also, I am aware and agree that an Administration Fee is payable by me if I choose not to accept the terms and conditions of the approved coverage.
I hereby certify that to the nest of my knowledge, all the statements and answers on the application for Insurance are true.
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