Personal Statement Of Health For Revival Of Policy

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Version 1.2
PSRF598813071602
Comp/June/Int/4689
Personal Statement of Health for Revival of Policy
Policy Number: _____________________________ Branch:
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Name of the Life Assured:
Name of the Proposer:
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(if different from the Policyholder)
Marital Status:
Single
Married
Divorced
Widow / Widower
Address:
Mobile no.*:
Telephone no.(R)*:
Email ID*:
*Contact details provided herein will be updated for all future communications. The above mentioned contact number will be considered as consent to communicate with him / her on
the contact details provided herein.
Reason for Lapse:
Present Occupation:
Gross Annual Income in `:
(From all sources) (figures in digits)
Name and address of the present employer OR
business premises if self-employed:
Please provide the information required below pertaining to the Life Assured from the date of policy application till date.
A . Personal health details:
1. Have you suffered from any of the following conditions mentioned below ?
Mention details, as applicable
Yes
No
a) Cardiovascular disorders such as chest pain, heart attack, arrhythmia, palpitations,
giddiness, anxiety, Cardiomyopathy, Hypertension/High Blood pressure, Coronary artery
bypass grafting (CABG), Angioplasty (PTCA ) or any other heart related conditions.
b) Respiratory disorders such as bronchitis, asthma, wheezing, pneumonia, tuberculosis,
any other disease of chest and lungs.
c) Gastrointestinal system disorders- Gastritis, ulcer, hernia, disease of liver, pancreas,
spleen, stomach, disease of short and long intestine, Jaundice, etc.
d) Urinary system disorders such as disorder related to kidney, urinary bladder, ureter,
prostate, hydrocele, etc.
e) Nervous system disorders such as paresis, transient ischaemic attack, paralysis,
Stroke, Alzheimer, Parkinson’s, meningitis, multiple sclerosis, epilepsy, blackouts,
migraine or any other disorder or tumor of brain, spinal cord or nerves. Mental disorders
such as major or minor depression, Obsessive Complusive Disorder, addictions, uncured
insomnia, anxiety or nervous breakdowns.
f) Ear, Nose, Throat, Mouth system disorders such as ear discharge, nose bleeding,
deafness, blindness, hearing loss, etc. Skin disorders such as varicose veins, psoriasis,
eczema, moles or dermatitis. Musculoskeletal disorder such as Arthritis, gout,
rheumatism, disc prolapse, fracture history, Osteoporosis, back pain, disorders of bones
or any other conditions.
g) Diabetes/ elevated blood sugar/sugar, ketone, proteinuria or diabetes related compli-
cations such as diabetic coma or any other hormonal diseases related to Thyroid gland or
any other hormonal imbalance.
h) Cancer or tumour or benign tumour or cyst, lump, enlargement of lymph nodes or any
other growth.
i) Blood disorders such as anemia, haemophilia, thalassaemia, leukaemia or any other
blood disorder or suffered from dengue, swine flu or encephalitis.
2. Have you undergone any lab test including HIV & HBsAg, radiological test or any special
investigation test such as ECG, MRI, CTMT, etc. or suffered from any accidents, injury,
major burns or advised hospitalisation?
3. Do you have any recurrent medical condition, physical disability, deformity, any illness
or injury that has kept you away from work?
4. Have you or your spouse been tested positive for HIV / AIDS or Hepatitis B or C or have
been tested / treated for other sexually transmitted diseases OR are you awaiting the
results of such a test?
5. Are you currently in good health?
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