Form 720 - Personal Statement Regarding Health
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3F. NO. 720
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 under C.D.A. Plan with deferment period 10 years or
more on the date of proposal or revival of policy.
Divl. Office:
Branch Office:
Prop./Policy No
Agent’s Name
Agent’s Code No.
1. Full name of the Proposer
(IN BLOCK LETTERS )
Address1
Full
Address2
Address
Address3
Email Address
Phone/Mobile No
2. Full name of the Life Assured/Life to be Assured
( IN BLOCK LETTERS )
Occupation
Name of Employer
Length of Service with
him
3. Is this application for
If the answer is ‘YES’ please give the Proposal Number
or the Policy Number
Proposal No :
(a) Issue of a new Policy?
Policy No
:
(b) Revival of lapsed Policy?
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
'Yes' or 'No'
mentioned policy :
and duration, doctors consulted
(a) Has he/she suffered from any illness/disease
a)
requiring treatment for a week or more?
(b) Did he/she have any operation, accident or
b)
injury?
c)
(c) Did he/she undergo ECG, X-Ray, Screening,
Blood, Urine or Stool examination?
Revival of Lapsed Policy (Form 720).
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