Declaration Of Good Health Form

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Declaration of Good Health
Policy Number: _______________________________________
Name of the life assured: _________________________________________________________
Questions pertaining to the life Assured
Yes
No
Details
1. Are you at present in good health?
2. Are you physically handicapped or having
any other deformity?
3. When were you in a hospital last? For
how many days? For what illness?
4. Have you ever suffered from any of the
following: heart dysfunction, kidney
dysfunction, high blood pressure,
diabetes, cancer, liver dysfunction, blood
abnormality or any other heath ailment?
Declaration: I hereby apply for revival of the above mentioned policy, which under its terms is now lapsed. As a basis for such revival, I hereby declare that each of the above
representations and statements made or referred to is true and correct, and that I have fully stated all details of each answer after understanding the same. I understand that
in case the company so desires, I may be required to submit further documents / undergo further medical tests, for the revival to be considered. I agree that if any of the
statements, answers or declarations made herein are found to be untrue or if any material fact has been found to be suppressed, the Company shall be entitled to cancel the
reinstatement of the Policy or repudiate the claim if any, arising out of such reinstatement and such reinstatement shall be treated as null and void and all the monies paid
thereof shall stand forfeited to the company. I hereby agree that the company has every right to revive the policy on terms other than the existing terms of the contract or to
reject the revival. I hereby agree that, if the Life Assured commits suicide for any reason, while sane or insane, within one year from the date of acceptance of revival of the
lapsed policy, the liability of the Company shall be limited to the Surrender Value (or) fund value, if any, that has accrued on the policy. I further agree that any payment made
or to be made in connection with this application shall be considered as deposit only and shall not bind the Company until this application is finally approved and
communicated by the Company. If this application is not approved, I also agree to accept refund of the above deposit amount made in connection herewith, without interest.
Signature of the life assured _______________________________
Signature of the proposer (if any) ___________________________
Date:

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