Form 700 - Personal Statement Regarding Health
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4F. NO. 700
Office use only
Date of Receipt _____________
(Established by the Life Insurance Corporation Act, 1956)
Inward No.
_____________
PERSONAL STATEMENT REGARDING HEALTH
For a policy on another life except for C.D.A. Plan with deferment period 10 years
or more on the date of proposal or revival of a Policy. Do not use this form if the
policy has vested in the life assured or has been assigned to the life assured.
Divl. Office:
Branch Office:
Prop./Policy No
Agent’s Name
Agent’s Code No.
Following questions to be answered by the Proposer
1. Name in Full of the Proposer
( IN BLOCK LETTERS )
Address1
Full
Address2
Address
Address3
Email Address
Phone/Mobile No
2.Name in Full of the Life to be Assured/Life
Assured (IN BLOCK LETTERS )
Occupation
Name of Employer
Length of Service with
him
If the answer is ‘YES’ please give the Proposal
3. Is this application for
Number or the Policy Number
(a) Issue of a new Policy?
(a) Proposal No.
(b) Revival of lapsed Policy?
(b) Policy No.
Following questions to be answered by the Life to be assured / Life Assured
4. Since the date of your above mentioned
Answer
Proposal / since the date of proposal for the above
If ‘Yes’ give details of ailment date and
'Yes' or 'No'
mentioned policy :
duration, doctors consulted.
(a) Have you suffered from any illness/disease
a)
requiring treatment for a week or more?
(b) Did you ever have any operation, accident or
b)
injury?
(c) Did you ever undergo ECG, X-Ray, Screening,
c)
Blood, Urine or Stool examination?
Revival of Lapsed Policy (Form 700)
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