Form 680/683 - Revival Of Lapsed Policies Both Medical And Nonmedical Basis - Life Insurance Corporation Of India
ADVERTISEMENT
1
2LIFE INSURANCE CORPORATION OF INDIA
F.No. 680 / 683(Rev .75)
(Established by the Life Insurance Act, 1956)
Date of Receipt
PERSONAL STATEMENT REGARDING HEALTH
(Revival of Lapsed Policies both Medical & Nonmedical basis)
Inward No.___________
Agent’s Name ____________________________
Pune Divisional Office :-_____________ Branch Office ____________ Policy No __________________________
1. Full name of the Life Assured
(IN BLOCK LETTERS) ________________________________________________________________________
Full Address _________________________________________________________________________________
Occupation ______________ Name of Employer __________________Length of Service with him ____________
2. Since the date of your proposal for the
Answer
If `Yes’ give details of ailment date & duration
above mentioned Policy :-
Yes or No
doctors consulted.
(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) Have you had a electrocardiogram, X-Ray
or Screening, blood urine or stool
examination?
3 a). Has a proposal or an application for revival of a policy on
a) ____________________________________
your life made to this or any other Office of the Corporation of
any Insurer ever been:
(i) Withdrawn or dropped?
(i) ___________________________________
(ii) Accepted with an extra premium or lien?
(ii) ___________________________________
(iii) Deferred or declined?
(iii) ___________________________________
(iv) Accepted on terms otherwise than those proposed?
If so, give details
(iv) ___________________________________
b) Is any proposal or an application for revival of a Policy
If answer is `Yes’ give the following details
on your life under consideration of this or any other office
(i) Proposal No. _________________________
of the Corporation ?
(ii) Policy No. ___________________________
4. Are you at present in sound health?
__________________________________________________
N.B. :- For Revivals under non-medical scheme (Question Nos. 6 & 7)
5. (I) State your height (without shoes) ___________ cms.
(ii)Your weight (with thin clothes) ___________ kgs.
6.. State below of all your Policies issued and / or revived under any of the scheme of the Corporation
.
Name of the
Policy No
Sum Assured
Year of issue
P & T
Med. /
Status
Bra. Office
Prop. No.
of Policy
Non Med
7. For Females only:-
(a) Since the date of your proposal under above mentioned Policy.
(I) Have you been menstruating regularly?__________ (ii) Have you had any miscarriages?_________________
(iii) Have you suffered or are you suffering from any disease of breast, ovaries or uterus?___________________
(b) State the date of last menstruation______________ (c) State the date of last delivery___________________
(c) Are you pregnant now? _____________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ct-33-a/att - Schedules A, B, C, D, And E - Attachment To Form Ct-33-a - Life Insurance Corporation Combined Franchise Tax Return - 2012
Financial
Form Ct-33-a/att - Schedules A, B, C, D, And E - Attachment To Form Ct-33-a - Life Insurance Corporation Combined Franchise Tax Return - 2014
Financial
Form Ct-33-a/att - Schedules A, B, C, D, And E -attachment To Form Ct-33-a - Life Insurance Corporation Combined Franchise Tax Return - 2013
Financial
Form Ct-33-a/b - Subsidiary Detail Spreadsheet - Attachment To Form Ct-33-a - Life Insurance Corporation Combined Franchise Tax Return - 2012
Financial
Related Categories
Parent category: Legal