4.

Are you at
in sound health?
N.B. - For Revivals under Non-medicalscheme (euestion Nos. s & 6)
(i) State your height (without shoes
(ii) Your weight (with thin ctothes.

5.

6. State below, details of all your po_licies issued and/or revived under any of the
Non-Medical Schemes of the Corporation:
Name of the Divl. Office
. Office Servicing the

Status of the
Policy

Policy Number

or Females onlv:
Since the date of your
under the above

mentioned policy:

been menstruatinq reqularlv-1

ii) Have you had any

iv) State the date of last menstruation

v) State the date of last deliverv.

DECLARATION

t.

do hereby declare that the foregoing statements and answers are true and complete
in
every particular, and agree and declare that these statements and this Oecfaratioh
;l;ng
with my froposal for lndurance under the lapsed potily lnarl be the basis
of the contract of
revival of the lapsed policy between me and Life insur'ance corpotitrn
orlndia,
any untrue averment be contained therein, the said contract dnatt Oe absolutelyand that if
nufl inO
void and all monevs which shall have been paid in respect thereoi, lfrarr?ano
forfeited to

the Corporation.

And I further declare that if between the date of this declaration and the date of revival
the policy (i) any change.in any occupation or any loulire circumstances connected of
with
my financial position oi.the geheral tieatth of my6etf oi tn"t oii;t;;;"r
ot
my
iamiiy
occurs or (ii) a Proposal for assurance or any application for r""uiuit oi" pbri.v
mv rii6
to any O-fficg of the Corporation is pending or-has been withdrj*n oroni
Tqd"
dropped,
deferred or declined or.acceptecj at an increbsed piurir* or subject to
iiien
other than as proposed, t sn'att forthwith intimate ine same to the Corporation or on terms
in writing to
reconsider the terms of Revival of the Policy. Any omission on my part
to do so shall render
the Revival absolutely_null and void and ali ro'ieyJ *r,ii,n snarrhSve
b!j; paid in respect
thereof, shall qtand
forfeited to the Corporation.

Dated at

day of

(month) 20

Signature of Witness

Name
Occupation
&

Address

:
:
.

Signature or Thumb impression of the Life Assured

Revival of Lapsed policy (Form 680).

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