(CPW 500 P x 100 LPSF 32/13. F No 680 (Rev. 87) LIC) (Established by the Life Insurance Corporation Act. 1956) PERSONAL STATEMENT REGARDING HEALTH (Revival of Lapsed policies on both Medical / Non-Medical Basis) Date of Receipt POLICY No, Branch Office Divisional Otfice Agent's Name 1, Full Name of the Life Assured soon Present Age (in BLOCK LETTERS) Full Address QcCUpatION nn rrnmmnmnnnneeeee Name of Employer Longth of service with him 2. Since the date of your proposal for the above | Answer | If “Yes", Give details of ailment such as mentioned Policy: “Yes' or ‘No’ | nature of ilness, date of onset, duration of iiness, ete (a) Have you ever suffered from any iliness / disease requiring treatment for a week or more for For Otfice use only Asthma, TB, BP, Ulcer, Kidney, Prostate, Urinary System, Diabetes, Hernia, etc. Age Yrs NMG SM (0) Did you ever have any operation, accident or wt ange = injury ? (© Dia you ever have undergone ECG, X-Ray DGH inorder Revival authorised Screening, Blood, Urine or Stool examination ? (©) What deaths or iness have been in your family ? HGA// AAO / Sr/ BM. Date 3. (a) Has a proposal or an application for revival of a Policy on your life made to this or any other office of the Corporation or any Insurer ever been : () Withdrawn or dropped? (i Accepted with an extra premium or lien? (ii) Detorted or declined? (iv) Accepted on terms otherwise than those proposed It s0, give details (b) Is any proposal or an application for revival Mt answer is “Yes", give the following of a lapsed policy on your lite under Ootalle consideration of this or any other office of (i) Proposal No. the Corporation? (li) Policy No. 4. Are you at present in sound health ? 5. Have you paid any deposit or arrears of premium ? If so give details. Amt. Rs. How paid. Date N.B. : For revivals under Non-medi scheme Question Nos. (5 & 6) rs6. (i) state your height (without shoes) ems. (ji) Your weight (with thin clothes) .. Kgs, 7. State below details of all your Policies issued and / or revived under any of the Non-medical Schemes of the Corporation Name of the Div. Office / Unit Branch Office Policy Number Sum Assured Status of the Policy For Female lives only 8. Since the date of your proposal under above mentioned Policy () Have you been menstruating regularly? (i) Have you had any miscarriage's? (ii) Are you pregnant now? (iv) State the date of last menstruation (v) State the date of last delivery .. (vi) Have you ever suffered from any disease of breast, ovaries or uterus. DECLARATION \ do hereby declare that the foregoing statements and answers are true and compote in every particular and agree and declaro that these statements and this declaration along with my proposal for Insurance under the lapsed Policy shall be the basis of the contract of revival of the lapsed Policy between me and Life Insurance Corporation fof india and that if any untrue averment be contained therein the said contract shall be absolutely null and void and all ‘moneys which shall have boen paid in respect thereo! shall stand forfeited to the Corporation. ‘And | further dectare that if between the date of declaration and the date of revival of the Policy (i) any change in my ‘occupation or any adverse circumstance connected with my financial position or the general health of myself or that of any member of my family occuts or (li) a proposal for assurance or any application for revial of Policy on my lile made to any Office of the Corporation is pending or has been withdrawn or dropped, deferred or declined or accepted at an increased [premium or subject to allen or terms other than as proposed, | shal forthwith intimate the same to the Corporation in writing to reconsider the terms of revival of the policy. Any omission on my part to do so shall ender the revival absolutely null and void and all moneys which shal havo ‘bean paid in respect thereot shal stand forfelted to the Corporation, Dated at on the . day of 201 Signature of Witness. > ‘Signature or Thumb impression ofthe Lite Assured Occupation & Address It in this form the answers to the question and / or signature of the Life Assured are given in vernacular then the life Assured should deciare 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 person filing the for, Name & Address of the declarant In case The Life Assured is illiterate : (2) The thumb impression of the Life Assured should be attested by a person of standing whose identity can easily be established, but unconnected with the Corporation and this declaration should be made by him, Name & Address of the declarant (1) | hereby deciare that | have fully explained the above questions to the proposer and | have ‘tuthfully recorded the answers given by the Lito Assured. Signature (2) hereby declare that | have explained the contents ofthis form to the Life Assured in (language) and that | have read out to the Life Assured to the answers to the questions dictated by the Life Assured ang that Life Assured has affixed his thumb impression to this form after fully understanding the contents thereot Signature