Form 680 - Personal Statement Regarding Health
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3F. NO. 680
( Rev. 680 )
Date of Receipt _____________
(Established by the Life Insurance Corporation Act, 1956)
Inward No.
_____________
PERSONAL STATEMENT REGARDING HEALTH
(Revival of Lapsed Policies on both Medical & Non-Medical basis)
Agent’s Name :
Divl.
Policy No
Branch Office:
Office:
1. Full name of the Life Assured
Address1
Full
Address2
Address
Address3
Email Address
Phone/Mobile No
Occupation
Length of
Name of Employer
years
Service with him
If 'Yes" give details of
Answer
ailment such as nature of
2. Since the date of your Proposal for the
'Yes' or 'No'
illness,
date
of
onset,
above mentioned Policy:
duration of
illness etc.
(a) Have you ever suffered from any
illness/disease requiring treatment for a
week or more?
(b) Did you ever have any operation,
accident or injury?
(c) Did you ever undergo ECG, X-Ray,
Screening, Blood, Urine or Stool
examination?
3. Has a proposal or an application for revival of a policy on your life made
to this or any other Office of the Corporation or any Insurer ever been:
(i) Withdrawn or dropped?
(ii) Accepted with an extra premium or lien?
(iii) Deferred or declined?
(iv) Accepted on terms otherwise than
those proposed?
If so, give details:
(b)Is any proposal or an application for revival of a. lapsed
policy on your life under consideration of this or any other
Office of the Corporation?
(i) Proposal No.
If answer is 'Yes' give the
following details:
(ii) Policy No.
Revival of Lapsed Policy (Form 680).
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