Form 680 - Personal Statement Regarding Health (Page 2 of 3) in pdf

4. Are you at present in sound health?

N.B. - For Revivals under Non-medical scheme (Question Nos. 5 & 6)

(i) State your height (without shoes)

cm.

(ii) Your weight (with thin clothes.)

kgs

6. State below, details of all your policies issued and/or revived under any of the

Non-Medical Schemes of the Corporation:

Name of the Divl. Office

/Unit

Status of the

Policy Number

Sum Assured

Br. Office Servicing the

Policy

For Females only:

7. Since the date of your

(i) Have you been menstruating regularly?

proposal under the above

(ii) Have you had any

miscarriage/s?

mentioned policy:

(iii) Are you pregnant now?

(iv) State the date of last menstruation:

(v) State the date of last delivery:

DECLARATION

……………

do hereby declare that the foregoing statements and answers are true and complete in

every particular, and agree and declare that these statements and this declaration along

with my Proposal for Insurance under the lapsed policy shall be the basis of the contract of

revival of the lapsed policy between me and Life Insurance Corporation of India, and that if

any untrue averment be contained therein, the said contract shall be absolutely null and

void and all moneys which shall have been paid in respect thereof, shall stand forfeited to

the Corporation.

And I further declare that if between the date of this declaration and the date of revival of

the policy (i) any change in any occupation or any adverse circumstances connected with

my financial position or the general health of myself or that of any member of my family

occurs or (ii) a Proposal for assurance or any application for revival of a policy on my life

made to any Office of the Corporation is pending or has been withdrawn or dropped,

deferred or declined or accepted at an increased premium or subject to a lien or on terms

other than as proposed, I shall forthwith intimate the same to the Corporation in writing to

reconsider the terms of Revival of the Policy. Any omission on my part to do so shall render

the Revival absolutely null and void and all moneys which shall have been paid in respect

thereof, shall stand forfeited to the Corporation.

Dated at

on the

day of

(month) 20

Signature of Witness

Name

Occupation :

& Address

Signature or Thumb impression of the Life Assured

Revival of Lapsed Policy (Form 680).

Page 2 of 3

Form 680 - Personal Statement Regarding Health Page 2

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