I declare that the statements and answers made in this form are true and complete to the best of my knowledge and belief and I agree that this statement together with any statement made to the Medical Examiner shall be the basis of the contract between me and the Company. If any untrue statement be contained therein, or if there be any material concealment, the contract of insurance shall be absolutely null and void and all moneys paid in respect thereof shall be forfeited to the Company. I fully understand that the Company will not be on the risk on my life until the issue of the formal letter of acceptance by the Company and the payment of the due premium by me.