Form 700 - Personal Statement Regarding Health (Page 3 of 4) in pdf

Form 700 - Personal Statement Regarding Health Page 3

Signature of Witness

Name

Occupation & Address

Signature or thumb impression of the Life to be

Assured/Life Assured

I do hereby declare that the foregoing statements and

Signature of Witness

answers are true and complete in every particulars

Name

Occupation & Address

Signature of the Proposer

(if the life to be assured/life assured is under 18 years)

DECLARATION BY THE PROPOSER

( name of Proposer )

do hereby declare that the statements and answers under heading 1 to 3 are true and

complete in every particular and I do hereby agree and declare that these statements and this

declaration together with statements and answers under heading 4 to 10 made by the *life

assured/ life to be assured and relative declaration thereto shall be the basis of contract of

*assurance/revival of the policy, between me and Life Insurance Corporation of India, and

that if any untrue averment be contained therein, the said contract shall be null and void and

all moneys which shall have been paid in respect thereof, shall stand forfeited to the

Corporation.

( *Delete words not applicable )

** And I further declare that if between the date of this declaration and date of revival of this

policy, (i) any change in the occupation of the life assured or any adverse circumstances

connected with my financial position or general health of the life assured or that of any

member of his family occurs or (ii) a Proposal for assurance or any application for revival of a

policy on the life of the life assured made to any Office of the Corporation has been

withdrawn or dropped, deferred or declined or accepted with an increased premium or subject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 acceptance . Any omission on my part to do

so shall render this Assurance invalid and all moneys which shall have been paid in respect

thereof, shall stand forfeited to the Corporation.

(** Not Applicable in case of an application for issue of a new policy.)

Dated at

on the

day of

(month)

Revival of Lapsed Policy (Form 700)

Page 3 of 4

Form 700 - Personal Statement Regarding Health Page 3