94 
Post- Office Insurance for Labourers. 
questions lollovving, are to the best of my knowledge and belief correct, and that 
they shall form the basis of my contract with the Postmaster-General. 
Witness my hand this day of (month and year). 
I was born at , iu the County of , on the 
day of , in the year 18 . My usual calling or occupation is 
that of a , and my usual weekly wages are not more than 
shillintrs. 
Questions. 
1. Are you of sober and temperate 
habits ? 
2. Are you now in good health ? 
3. Ha.ve you been a whole month 
sick within the last 3 years, and, if so, 
when ? 
4. Have you had gout, rheumatism, 
spitting of blood, rupture, palsy, fits of 
any kind, or asthma '? 
5. Who is your medical attendant? 
6. To whom do you refer for cha- 
racter ? 
Proof of age, either register of birth or of baptism, or other 
satisfactory evidence, shall be appended to the proposal paper. 
In case the proposer should desire to insure at the same time 
for old-age-pay, he shall fill up the following Form : — 
Old Age Fay. 
I, , do also propose to make an Insurance for 
(65) 
shillings weekly, to be due to me after the age ot < or \ years, and I am willin 
(to) 
[ Co 
to ]iay per month for the same till •! or 
( 70.) 
Witness my hand this day ol (month and 3'ear). 
Medical Paper. 
known to 
Answers. 
Questions 
1. Is the proposer . 
you ? 
2. Date of your report ? 
3. Is lie without disorder or disease, 
and sound and without deformity of 
body or limb? If deformity or disease, 
what is it ? 
4. Has he any tendency to asthma, 
fit, rheumatism,, jnilmonary, or any | 
scrofulous di.sorder ? j 
5. Doi's he appear to be a healthy ' 
man of temperate habits ? 
Medical (Certificate. 
1, , recommend the l\)slmaster-( ieneral to accept 
the jirojiosal of the above named , of 
(Hate, and Signature of Medical l Aaminer.) 
