Personal Statement Of Health For Revival Of Policy Page 2
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1
2Yes
No
Mention details, as applicable
6. Female Specific health disorders
a) Have you had any disease of uterus, breast, cervix, ovaries or have
undergone hysterectomy?
b) Have you undergone PAP smear, mammogram or USG pelvis?
c) Are you currently pregnant? If yes, how many weeks? ______________
B. Family medical history:
Has any death or illness occurred in your family (parents or siblings)? If yes, then mention
the age at death and cause of death / nature of illness.
Indicate by ticking
Mention details, as applicable
in relevant box
C. Other personal details:
*Please attach a separate sheet in
Yes
No
case the space is inadequate
1. Do you have any current active insurance cover or has any of your life insurance / health
Reason: _________________________
insurance / rider been accepted with extra premium, accepted on other special terms,
postponed, declined or not taken up by you?
2. Have you submitted any simultaneous applications for insurance to any of our offices
Proposal / Policy No.: _______________
or another insurance company which is still pending OR are you likely to revive any lapsed
Sum assured: _____________________
policies?
Company Name: ___________________
3 . Have you ever made any claims for hospitalisation or surgery or critical illness benefit
under this policy or any other health insurance policy from any other company?
4. Do you take part in any adventurous sports or hobbies? (like paragliding,
mountaineering, deep sea diving , motor racing, bungee jumping, etc.)?
5. Have you ever resided overseas for more than 6 months or do you intend to travel
Past Travel: _____________________
overseas in the next 6 months and reside for more than 2 months?
Future Travel: ____________________
7. a. Height- Feet
inches
OR Centimeters
b. Weight -
( Kgs)
8. Please give the habits details as follows :
Substance consumed
Do you consume?
If yes, please provide details
Quantity
Alcohol
Units* / Week
Beer
Wine
Spirit
Others
Yes
No
*(1 unit = 330 ml of beer / 30 ml of spirits /
125 ml of wine)
Tobacco
Cigars
Cigarette
Bidi
Units * /Day
Yes
*(1 unit equivalent to 1 cigar / 1 cigarette / 1
No
Chewing Tobacco
Others
bidi. If chewing tobacco, please specify how
many grams per day .)
Addictive or intoxicating drugs (example
, Heroin, Cocaine, Marijuana, Charas, etc.)
Ganja, Hashish
Yes
No
Declaration from the Life Assured:
I hereby declare that all the information given by me/on my behalf is true and I have not withheld any material fact within my knowledge. I agree that the
information provided in this declaration along with my proposal for insurance shall be the basis of contract of revival of the lapsed policy. I also agree and
understand that the application for revival of the policy will be considered by the Company at its sole discretion. I declare that, I do not have any history of
conviction under any criminal proceedings in India or abroad.
SIGN HERE
DD/MM/YYYY
Date : ________________________
Signature of the Life Assured
Place : ________________________
( To be signed by the Policyholder if the
Life Assured is a minor )
Declaration from the Policyholder (If Policyholder is different from the Life Assured ):
I hereby declare that all the information given by me/on my behalf is true and I have not withheld any material fact within my knowledge. I agree that the
information provided in this declaration along with my proposal for insurance shall be the basis of contract of revival of the lapsed policy. I also agree and
understand that the application for revival of the policy will be considered by the Company at its sole discretion. I declare that, the Life Assured does not
have any history of conviction under any criminal proceedings in India or abroad.
SIGN HERE
DD/MM/YYYY
Date : ________________________
Place : ________________________
Signature of the Policyholder
Declaration made by third party where the Policyholder has affixed his/ her thumb impression/ has signed in vernacular:
The Policyholder has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this
application form has been explained to the Policyholder in __________________ language and have truthfully recorded the answers provided to me. I
further declare that the Policyholder has signed/affixed his/her thumb impression in my presence.
DD/MM/YYYY
Name: ________________________________________________________ Date: __________________ Place: _______________________________
SIGN HERE
Address: _________________________________________________________________________________
IRDAI Registration No. 101.
HDFC Standard Life Insurance Company Limited. In partnership with Standard Life Plc. CIN:U99999MH2000PLC128245.
Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Mon-Sat from 10 am to 7 pm |
Email – | NRI (For NRI customers only) Visit –
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