9 HAVE YOU EVER SUFFERED OR DO YOU NOW SUFFER FROM: (For 'Yes' answers indicate the ailment or ailments)
a) Cerebral or spinal complaints (epilepsy, fits or fainting attacks, temporary insanity, vertigo, nervous disease or nervous breakdown,
frequent headaches, or any other nervous affection or mental disturbances) ?
b) Disease of the respiratory organs (huskiness, frequent catarrh, consistent or habitual cough, pains in the chest, blood - spitting,
pleurisy, inflammation of~the lungs, catarrh of the pulmonary apex, tuberculosis, asthma, pneumonia etc.)?
c) Disease of the heart or blood vessels (palpitation, breathlessness particularly when climbing stairs, spasms or pain in the
neighborhood of the heart, dropsy or edema in the face, hands or feet, high blood pressure)?
d) Diseases of the digestive organs (blood vomiting, bleeding from bowels, stomach ache, gastric or duodenal ulcer, gall bladder
complaints, liver complaints, long spells of indigestion, diarrhea or tendency to diarrhea, appendicitis, fistula, dysentery or jaundice)?.
e) Diseases of the urinary organs (any infection of kidneys, urinary or genital organs, kidney stones, stones of the bladder, turbid or
blood stained urine, difficulty in passing urine,structure, gravel, albuminuria, or diabetes)?
f) Gonorrhea, soft cancer, syphilis or other venereal disease?
g) Any complaint of the ears, especially flux or discharge or Ocular affection?
h) Acute articulural rheumatism or gout?
i) Rheumatic fever or fever of any kind?
j) Malaria, bilharzia or ankylostoma ?
k) Glandular complaints (scrofula, glandular T.B. etc.)?
10. Please give full details for any 'Yes' answer to 9a through 9k (if space provided not sufficient, attach separate sheet)
Disease or Date No. or Duration of Permanent result, if Medical Attendant's
Ailment Attacks each Attack any Name Address
11. Have you ever (Please give full details at the end to all "Yes" answers, if space provided not sufficient, attach a separate sheet of paper):
a) had unexplained, recurrent or persistent fever or skin disorder?
b) had unexplained persistent night sweats? c) had unexplained weight loss?
d) had unexplained infections or swollen glands? e) had chronic or frequent diarrhea?
f) had persistent cough? g) been refused as a blood donor?
h) had hepatitis B or any sexually transmitted disease including genital sores or discharges?
i) received any blood transfusions within the last five years?
j) had or been advised to have a blood test for AIDS or an AIDS-related conditions?
Details if any
12. For Females only
a) Have you ever suffered from any disease of the breast or sex-organ?
b) Have you ever had any premature birth, still birth or miscarriage or cesarean section? If yes, when and how often?
c) Are you now pregnant? If yes, how many months of conception have passed?
13. Is there any other fact or circumstance about you, your health and way of living which was not specifically mentioned
above which affects your eligibility for assurance? Please give details
14. Who has initiated and persuaded you to purchase life assurance?
DECLARATION: I, the undersigned, whose life is proposed for assurance, do hereby declare that the statements in this proposal are true
and complete and I hereby give my consent to the Company to seek information from any doctor who has ever attended me and from any
Life Assurance Office to which a Proposal on my life has at any time been made, and the giving of such informa tion is hereby authorized. I
further agree that this Proposal and Declaration and the statements made above or to any medical examiner acting for the Company shall be
the basis of the proposed contract between the Company and myself. I also do under stand and agree that if anything contrary to the truth be
stated or if any information which ought to be made known to the Company with reference to the Proposed Assurance be withheld or
concealed, any policy which may be granted in pursuance of this Proposal shall be null and void. I further have understood and agreed that
the Company is not on risk until acceptance of this Proposal is communicated to me in writing.
Signature of Life to be Assured Signature of Proposer (if different from Assured)
Signed on this________day of________________ Signed on this _________________ day of________________
Witness:
1. Name________________________ Signature ___________________ Address_______________________
2. Name________________________ Signature ___________________ Address_______________________
