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DECLARATION

I _________________________________________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 contract of revival of the lapsed Policy

between me and the Life Insurance Corporation of India and that if any untrue averment be contained therein the

said contract shall absolutely be null and void and all moneys which shall 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 my 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 (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Policy on my life made to any Office of the Corporation is pending or has been withdrawn or dropped, deferred or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.

Addendum to the Form of Declaration of Good Health

Declaration after revival of a policy under Non- Medical Scheme

Re: Policy No.______________________

Name __________________________________________________

I hereby declare that at present I have not proposed for any fresh insurance to the Life Insurance Corporation of

India and further declare that in case of I propose for a new Non-Medical Scheme, I shall stat in that this Policy

Number _________________ was revived by the Corporation on the strength of Declaration of Good Health only

only and hence it is to be treated as a policy issued under non-medical scheme. I hereby agree to abide by the

rules of the corporation with respect to their Non-Medical Scheme.

Dated at ___________________On the ______________ day of _________________20

Witness Signature ___________________________

Full Name __________________________________

Occupation & Address ________________________

Signature or Thumb Impression of the Life Assured

Dated at ___________________On the ______________ day of _________________20

Signature of Witness _______________________

Occupation & Address ____________________

Signature or Thumb Impression of the Life Assured

 “ If in this form the answer to the questions and/or signature of the Life Assured is given in vernacular then the Life

Assured should declare in his/her own handwriting above his own signature that all questions were explained to

him/her and that his replies were given after fully and properly understanding the same.”

1) This declarations should be made by the

I hereby declare that I have fully explained the above

Person filling in the form

questions to the Life Assured and have truthfully

recorded the answers given by the Life Assured.”

1) Name & ___________________________

Address _____________________________

of the

_____________________________

declarant ____________________________

Signature

In case the life Assured is Illiterate

The thumb impression of the Life Assured should be

“I hereby declare that I have explained the contents

attested by a person of standing whose identity can

of this form to the Life Assured in _____________

easily be established, but unconnected with the

(language) and that I have read out to the Life

Corporation and this declaration should

Assured and that the Life Assured has affixed his/

be made by him

her thumb impression to this form after fully

understanding the contents thereof.”

2) Name & ___________________________

Address _____________________________

of the

_____________________________

declarant ____________________________

Signature

Note : In case of dispute in respect of interpretation of terms the English version shall stand valid.

Form 680/683 - Revival Of Lapsed Policies Both Medical And Nonmedical Basis - Life Insurance Corporation Of India Page 2

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