Form 720 - Personal Statement Regarding Health (Page 3 of 3) in pdf

Form 720 - Personal Statement Regarding Health Page 3

Signature of Witness

Name

Signature or thumb impression of the

Occupation & Address

Proposer.

If in this form, the answers to the questions and/or signature of the Proposer are given in

vernacular, then the Proposer should declare in his own handwriting above his own signature that

all questions were explained to him and that his replies were given after fully and properly

understanding the same.

(1)This declaration should be made by the

(1) I hereby declare that I have fully explained the

person filling in the form

above questions to the Proposer and I have

truthfully recorded the answers given by the

Name

Proposer.

& Address

Of the

declarant

Signature

In case, the Proposer is Illiterate:

(2)The thumb impression of the Proposer should be

(2) I hereby declare that I have explained the

attested by a person of standing, whose identity can

contents of this form to the Proposer in

easily be established, but unconnected with, the

………………….. (language) and that I have read

Corporation and this declaration should be made by

out to the Proposer, the answers to the questions

him:

dictated by the Proposer and that the Proposer has

affixed his thumb impression to this form after fully

understanding' the contents thereof.

Name

& Address

Signature

Of the

declarant

Revival of Lapsed Policy (Form 720).

Page 3 of 3

Form 720 - Personal Statement Regarding Health Page 3