Page:20th annual meet- League of American Wheelmen, Aug. 14th to 19th '99, Boston, Massachusetts.djvu/15

Form 1B.160m.

Commercial Travellers' Eastern Accident Association,
President, Secretary and Treasurer, LAURIS J. PAGE. Vice-Presidents: J. HENRY BLANCHARD. FRANK L. ROBERTS. WILLIAM D. RAND. Counsel, MERRITT & MERRITT.	OF BOSTON Incorporated under the Laws of Massachusetts. Room 316, John Hancock Building, 178 DEVONSHIRE ST., BOSTON, MASS. INDEMNITY FOR ACCIDENT	Board of Directors: WALTER M. ROGERS, Chairman. EDWIN A. TOWNE. LAURIS J. PAGE. ANDER M. BENSON. CHARLES W. HALL. JAMES A. RICKER. Surgeon-in-Chief, ARTHUR W. BLAIR, M.D.

APPLICATION FOR MEMBERSHIP.

To be filled out, signed, and forwarded, with $2.00, to LAURIS J. PAGE, Secretary, P. O. Box 5169, Boston, Mass,
All Remittances mast be by Registered Letter, P.O. Money Order, Express Order, or by Draft on Boston.

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To the Board of Directors of The Commercial Travellers' Eastern Accident Association:—

I hereby apply for membership in the above-named association, and herewith enclose the entrance fee of two dollars.

1.

My full name is

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2.

My age is

⁠

years.

Height

⁠

ft.,

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in.

Weight

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lbs.

3.

My residence is (St. and No.)

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Town or City of ... State Of ....

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4.

I am a Commercial Traveller as described by Article 1 of the By-Laws,

printed hereon, and am employed by:

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⁠

5.

The principal place of business of my employer is (St. and No.)

⁠

⁠

Town or City of

⁠

State of

6.

The business of my employer is

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7.

My particular business is buying/selling

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8.

I travel

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months of each year, and over the following parts of

the country, viz

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9.

I carry

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samples, as follows, viz.

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10.

I do not carry any explosives or implements dangerous to life.

11.

I do not engage in setting up or running machinery, or in any dangerous operation.

12.

My habits are good, and I do not use intoxicating liquors to excess.

13.

I am in good health, and my body is sound and perfect, except as follows,

viz.

⁠

⁠

⁠

⁠

14.

{{hi|I have never received any severe bodily injury, or had any severe

illness or mental infirmity, except as follows, viz.

⁠

⁠

⁠

⁠

⁠

from all of which I have

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entirely recovered.

15.

I have

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other accident insurance in the following companies,

for the following amounts of weekly idemnity in each, viz.

⁠

⁠

⁠

⁠

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16.

I have never been rejected by any Accident Insurance Company or Association.

17.

In case of my death by accident I desire the death benefit paid to

NAME,

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ADDRESS,

⁠

Relationship to me^[1],

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18.

I hereby agree, if admitted to membership in said Association, to abide by its By-Laws, and Rules and Orders of its Board of Directors, and the limitations and conditions contained in its certificate of membership.

19.

I know that the indemnity paid by said Association can not exceed the amount received from one assessment of two dollars upon each member, or a proportional part of such amount, and will not in any event exceed the following amounts, viz:—

$5000	$5000	$5000	$2500	$2500	$1250	$25
In case of Death by accident.	Loss of both arms or both legs or arm and leg.	Loss of both eyes.	Loss of one arm or one leg.	Permanent total disability over 2 yrs.	Loss of one eye.	Weekly indemnity 52 weeks.

20.

I agree that any physician who treats me may disclose or testify to any facts which he may learn in his professional capacity concerning my mental or physical condition, hereby expressly waiving any legal objection thereto.

21.

My Post-office address, where all notices shall be sent is,—

Street and No.

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City or town

⁠

State

⁠

22.

I hereby warrant the above statements to be true, and that I have withheld no material fact.

Signature of applicant

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Dated at

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this

⁠

day of

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189

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Applications for membership are not binding until accepted by the Board of Directors.

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I recommend the above applicant.⁠

1. By the Statutes of Massachusetts (1894, c. 37), the indemnity, in case of the death of a member, must be payable to "the wife, affianced wife, relatives of, or persons dependent upon such member," and no certificate can be made payable to "myself," "my estate," "my heirs," "persons named in my will," or to any beneficiary other than designated by the statute above cited.