To the best of your knowledge, are you in good health? YES/NO if no, please explain
I/We the person/s by whom the Assurance is to be effected, declare that to the best of my knowledge and belief: I/We am/are in
good health, free from disease and disability or symptoms thereof. I/We agree that the foregoing answers and this declaration
and answers to the questions put shall be the basis of contract between me/us and Co-operatives Life Assurance. I/We also
understand that no natural death claim shall be payable during the first 30 DAYS from the effective date.