Any consumption, insanity, constitutional or hereditary disease in the family, other than appears above-i. e., among uncles or aunts? If so, state particulars.

Have any two members of the family, grandparents included, had consumption, cancer, paralysis or apoplexy, disease of heart or kidneys?

The Medical Examiner will please obtain from the party, as fully as possible, answers in detail. In giving cause of death, avoid all indefinite terms, as "General Debility," "Change of Life," "Fever," "Dropsy," "Exposure" or "Accident." If the word "childbirth is used, state how long after delivery death occurred, and whether there were any symptoms of disease of the lungs.

Has the party any predisposition, either hereditary or acquired, to any constitutional diseases, such as consumption, rheumatism, syphilis, insanity, gout, scrofula?

NUTRITION AND DIATHESIS.

Any history of malaria, rheumatism, gout, syphilis, tuberculosis, scrofula, cancer, tumors, glandular swellings or dropsy? Where answers are "yes" here and below, state particulars-i. e., date, duration, severity and results of the affection. Anything unfavorable in the general appearance, such as sickly aspect, or unduly full habit, or apparent proneness to fatty degeneration? Is there any evidence of former illness?

THE SKIN.

Any skin eruption, sores or ulcers; any history of skin disease or vestiges of the same? Has he had erysipelas, carbuncle, boils?

NERVOUS SYSTEM.

Any history of severe headaches, vertigo, loss of consciousness, convulsions, tumors, epilepsy, delirium tremens, paralysis, apoplexy, nervous exhaustion, mental derangement or spinal disease? Any present derangement of function, or suspicion of any lesion?

ORGANS OF SPECIAL SENSE.

Any history of otorrhoea or otitis?

Any serious impairment of sight or hearing?

RESPIRATORY ORGANS.

Number of respirations per minute? Is the character of the respirations other than full, easy, distinct and regular? Is there any history of hæmoptysis or spitting of blood, chronic catarrh, hoarseness or cough, shortness of breath, asthma, bronchitis, pneumonia, pleurisy?

Is there present impairment of function, or any abnormality, discoverable by means of physical diagnosis?

BLOOD VESSELS.

What is the rate and other qualities of the pulse? Count at least a minute. Is it intermittent or irregular? If the applicant is excited, wait and secure the normal rate. Is there any indication present of any disease of the heart or blood vessels? Any abnormality discoverable by auscultation or percussion? Any history of sunstroke, faintings, palpitations or cardiac pains; of varicose veins or bleeding piles; or any suspicion of atheroma or aneurism?

ALIMENTARY CANAL.

Any history of difficulty in swallowing, dyspepsia, chronic diarrhoea or dysentery, constipation, colic, jaundice or liver disorder, fistula in ano? Any present impairment of function or trace of organic disease?

URINARY ORGANS.

Specific gravity and reaction of the urine? The Examiner must have personal knowledge that the urine was voided by the applicant. Does it contain albumen? Employ the most accurate tests. Sugar? Examine for sugar carefully when the specific gravity is over 1.025. Color and appearance of urine? Frequency of micturition? Quantity voided in the twenty-four hours? Nature and amount of sediment?

Microscopical examination. Any casts? Blood? Pus? Crystals? Other elements? The microscopical examination is omitted unless required by the company in special cases, or when the policy is for an extraordinary

amount.

Is there any history of gravel, calculus, cystitis, nephritis, dropsy, diabetes?

ORGANS OF GENERATION.

Any history of venereal disease, stricture, prostatitis, enlarged prostate? Females.-Any menstrual disorder, history of uterine or ovarian disease, abortion or difficult labors? Is applicant now pregnant? Has she borne children; if so, how recently? Has she passed the climacteric?

GENERAL HEALTH RECORD.

Any history of serious illness, injury or deformity, not alluded to above? Are you satisfied that there is nothing in his physical condition, habits, personal or family history, not distinctly set forth, tending to shorten life? Is the applicant insured in this or any other companies? Has any proposition, negotiation or examination for life insurance been made in this or any other company or association, on which a policy has not been issued; if so, when and in what company?

Has applicant had smallpox or varioloid? Date of successful vaccination? Does scar exist?

PERSONAL HABITS.

Does he drink wine, spirits or malt liquors daily or habitually? If so, to what extent? Former habit of drinking intoxicating beverages? Does he now or has he ever used opium, chloral, tobacco, or other narcotics? Does he use tobacco to excess?

Are there any evidences of impaired health or constitution from the use of stimulants or narcotics?

MEDICAL ADVISER, ETC.

Name and address of applicant's regular physician; or, if there be none such, that of the physician last consulted, with the nature of the illness. Does the applicant expressly waive all provisions of law forbidding any physician who has attended him from disclosing all information thereby acquired? Do you desire any information from his medical adviser; if so, procure and submit it with this report.

Name and residence of an intimate friend, who may be referred to for information.

REMARKS.

(Here note any circumstances affecting the risk which do not appear in the foregoing answers.)

OPINION.

Compared with the average of lives of the same age and sex, does the "expectation of life" in this applicant seem to you "first class" or "fair" only, or “doubtful," or "bad?" If you were yourself in the business, would you grant this subject a life policy? (Answer conscientiously, independent of set rules and instructions; your own, honest, individual opinion is what is wanted.) If not for life, for what term of years would you issue a policy?

SIGNATURES, ETC.

Append the signatures and addresses of both applicant and Medical Examiner, with exact dates.

ADDITIONAL FEMALE CERTIFICATE.

In case the candidate is a woman, the following additional questions are required:

Name? Residence? Is she well formed; and do her weight, height and general appearance indicate a healthy person? Is she now pregnant? Are the functions of the uterine system in a healthy condition? Is any disease of the breast suspected; if so, what? Has she ever had prolapsus uteri, ovarian disease, or any disease of the genito-urinary organs? Are there tumors suspected in the womb or other part of the body? Has she ever miscarried? If so, how many times and under what circumstances? If she has borne children, how many, and were the labors natural and without serious results? Are you acquainted with any facts affecting her health not included in the above questions? Do you consider her safely insurable and recommend that a policy of insurance be granted? Date. Signa tures.

(Agents' Report and Instructions to Agents, see Appendix.)

INSTRUCTIONS TO MEDICAL EXAMINERS.

(Revised from the rules observed by the prominent companies.)
GENERAL RULES.

1. The company's latest issue of blank form of application must be used in all cases. Examine it carefully, and see that every question is correctly and definitely answered.

2. Conduct your examination in private, and not in the presence of the agent, or of others; except in the case of females, when it is often prudent to have your own witness present.

3. Applicants must be examined in the places where they reside or do business, unless otherwise desirable, and by the Examiner regularly appointed and accredited to such place. When the Medical Examiner is himself the applicant, he must be examined by another Medical Examiner regularly appointed in the same or in a neighboring place.

4. Applicants cannot be examined by Medical Examiners who are either their relatives or who may be directly or indirectly beneficiaries under the policy.

5. Make your report full and precise. Such report has to serve the Medical Directors at the home office as the basis of their professional judgment on the risk.

6. The Medical Examiner's report should be free from alterations, interlineations or erasures. When unavoidable, the same must be duly attested by the party entitled to make them, with date of such attestation.

7. Medical Examinations, to be accepted, must have been made within thirty days prior to the receipt of the application at the home office.

8. Particular attention should be paid to writing out the full name of the person examined.

9. He must date his examination the day it was made.

10. The company holds the Medical Examiner responsible for the identification of applicants, and he is instructed to make no examination unless the applicant is personally known or satisfactorily introduced to him. The same rule applies to persons presented for examination for certificates of health, which, in all cases, must be paid for by the applicant and must not be charged to the company.

II. A Medical Examiner who removes from the district to which he has been accredited forfeits his appointment. He may, at the discretion of the company, be reappointed for the district to which he has removed, provided there is a vacancy at that point.

12. An Examiner who signs as witness to an applicant's signature should state the reason therefor, and whether he has any interest in the transaction.

13. The home office expects the Examiner to notify it in every case where a policyholder may be violating the terms of the policy by vicious habits, or otherwise in any way tending to shorten life. Thus unjust claims may be avoided.

14. The Examiner should report any local cause of disease, which makes a particular residence unhealthy, and also whether there is anything in the occupation rendering life insecure. Persons not infrequently change their residence and business for sanitary reasons. Such reasons must be investigated.

15. If the applicant has ever applied, or been examined, for life insurance, and no policy issued, explanation of the reason for such non-issue of policy must be given, with date of rejection and name of company.

16. A Medical Examiner may solicit applications for insurance, and participate in the commissions accruing therefrom under the rules of each company, but he must, in every such instance, submit the applicant to another regularly appointed Examiner for examination. It is manifestly improper that he should act as Examiner and agent at the same time.

17. Where the application is from $20,000 to $30,000 or over, the applicant must be examined by two regular Examiners. Two large companies require three Examiners for amounts over $50,000.

18. The Medical Examiner's relation to the applicant for life insurance is opposite to that which he occupies in his professional capacity. In the latter case the patient exposes his infirmities, and even intensifies them; the applicant for life insurance, on the other hand, may desire to lessen their importance or conceal their existence.

19. The Medical Examiner is the guardian of the interests of the company. He is expected to furnish the company, on its appropriate blanks, an explicit and truthful statement of the age and physical condition of the