Académique Documents
Professionnel Documents
Culture Documents
133
1. LIFE to be Insured (To be filled in BLOCK LETTERS only) 2. PROPOSER (if not the LIFE to be Insured)
Title Mr. Mrs. Ms. Title Mr. Mrs. Ms.
Qualifications SSLC Under Grad Grad Qualifications SSLC Under Grad Grad
Post Grad. Others ___________ Post Grad. Others ___________
Occupation Business Service Professional Occupation Business Service Professional
Retired Student Agriculturist Retired Student Agriculturist
Housewife Driver Armed Forces/ Police Housewife Driver Armed Forces/ Police
Other ___________ Other ___________
Annual Income Rs.__________________________ Annual Income Rs.__________________________
Permanent Account No. (PAN) Permanent Account No. (PAN)
7. Payment Details
8.1 PERSONAL HEALTH RECORD OF LIFE TO BE ASSURED: (To Be Filled Only For “With Life Cover” Option)
Height : Cms Weight : Kg
In the past 6 months, has your body weight changed by more than 5 Kg? Yes No
If yes, please mention whether lost or gained and how many Kgs. Lost ; Gained ; Amount ____________ Kgs
Please state Cause of a change in weight_________________________________________________________________________________________________________________
Visible identification mark if any______________________________________________________________________________________________________________________
8.2 Health details of life to be assured
ii. Chest Pain, Palpitation, Rheumatic Fever, Stroke, Heart Attack, Heart Murmur, Shortness of Breath, or other Heart Disorders?
iii. Asthma, Bronchitis, Chronic Cough, Pneumonia, T.B., or any other respiratory or lung disorders?
viii. Dizzy / Fainting Spells, Epilepsy, Multiple Sclerosis, Tremors, Numbness, Double Vision, Insomnia, Depression, Stress related problems, Paralysis,
Nervous or Mental / Emotional Disorders?
ix. Urine, Kidney, Bladder, Reproductive Organ, Hydrocele or Prostrate Disorders?
B. Apart from the medical conditions mentioned above, have you in last five years
i) Suffered from any ailment / injury requiring treatment for more than a week?
ii) Undergone or are currently undergoing or advised to undergo any form of medical treatment, investigation or test?
iii) Consulted any doctor or other health practitioner except for common cold/influenza lasting less than 7 days ?
iv) Ever remained absent from your place of work on medical grounds for 7 consecutive days or more ?
2
C. Have you ever or are you currently suffering from any defect in sight, hearing or speech, or any physical impairment or disability or abnormality?
D. Have you or your spouse received medical advise, testing or treatment in connection with sexually transmitted disease or HIV infection, or suffered
from prolonged weight loss, Diarrhoea, enlarged glands or have been advised to abstain from donating blood?
E. Do you have any health symptoms or complaints for which a physician/ homeopath/ ayurvedic /alternative medical advisor has been consulted
or treatment received e.g. persistent fever, unexplained weight loss, loss of appetite, pain, swelling etc.?
If you have answered YES to any part of Question 8.2, please complete the table below & attach relevant questionnaire:
Illness, Injury or tests Date Commenced Type of treatment Duration of Illness/ Date of last symptoms Current Condition Full name and address of doctor
injury or hospital (if any)
In case of major sickness/operation, the special questionnaire, hospital/ doctor’s report has to be submitted.
Section 41 of the insurance act, 1938 : (1) No person shall allow or offer to allow either Section 45 of the Insurance Act, 1938 : “No policy of the life insurance effected before
directly or indirectly, as an inducement to any person to take or renew or continue an the commencement of this act shall after the expiry of two years from the date of com-
insurance in respect of any kind of risk relating to lives or property in India, any rebate mencement of this act and no policy of life insurance effected after the coming into
of the whole or part of the commission payable or any rebate of the premium shown on force of this act shall, after the expiry of two years from the date on which it was effected,
the policy, nor shall any person taking out of renewing or continuing a policy accept any be called in question by an insurer on the ground that a statement made in the proposal
rebate, except such rebate as may be allowed in accordance wit the published prospec- for insurance or in any report of a medical officer, or referee, or friend of the insurer, or in
tuses or table of the insurer. any other document leading to the issue of the policy, was inaccurate of false, unless the
Provided that acceptance by an insurance agent of commission in connection with a insurer shows that such statements was on a material matter or suppressed facts which
policy of life insurance taken out by himself on his own life shall not be deemed to be it was material to disclose and that it was fraudulently made by the policy-holder and
acceptance of a rebate of premium within the meaning of this sub-section if at the time that the policy holder knew at the time of making it that the statement was false or that
of such acceptance the insurance agent satisfiets the prescribed conditions establishing it suppressed facts which it was material to disclose;
that he is a bona fide insurance agent employed by the insurer. (2) Any person making Provided that nothing in this section shall prevent the insurer from calling for proof of
default in complying with the provisions of this section shall be punishable with fine age at any time if he is entitled to do so, and no policy shall be deemed to be called in
which may extend to five hundred rupees. question merely because the terms of the policy are adjusted on subsequent proof that
the age of the life insured was incorrectly state in the proposal”
Date: D D M M Y Y Y Y
Signature of the Declarant
The content of this proposal and documents have been fully explained to me and I have fully
Signature of the Witness Proposer’s Mobile/Telephone Number
understood the significance of the proposed contract
Name of witness
Address
Place Date
Confidential Report (To be completed by the Advisor after receiving the complete proposal form) Signature of the Life to be Insured Signature of the Proposer
I hereby declare that the proposal form has been completely understood by the client and facts
Name of Witness
disclosed therein are true and correct to the best of my knowledge and belief. I am satisfied with
the identity of this client and recommend proposal for acceptance
(if different of the Life to be Insured)
Place Place
Date: D D M M Y Y Y Y Date: D D M M Y Y Y Y
Signature of advisor Signature of Sales Manager