Waa m./GH st. No. 680 muc sans area sgt ents safer arta felt Date of Receipt Fear ; (cet agar etc are 1056 ar deena) a6 Inward No (hers aia Pie afte, 1956 gr seen) (Established by the Life Insurance Act, 1956) waft tet aafara at area tae dates vee, PERSONAL STATEMENT REGARDING HEALTH (deta sath Render ahora de Gade een (sareastien ef Re areata & sere at de aM & grea tg) Praca aa (Revival of Lapsed Policies both Medical & Nonmedical basis) aera a Agent's Name ae Rn wee ea aed ea otra fees Mumbai Divisional Office POLICY NO. 4, Rarer’ goat / ere ar spr AH /Full Name of the Life Assured (Gee sian, Ge ale IN BLOCK LETTERS) isat/ GIT Ful Addross ‘aretha oe Ft amar ord 4, Nature of KYC Documents Submitted____________Aadhar Card No sharfa w. | an # ta. Mobile No. / Contact No. Email iD: PAN No. sae aie area wae a ra REI Preteen or sath rer Sar ora Occupation ______Name of Employer____Length of Service with him ‘la Seater oaeTaen Rare P retary ae a S faaeor fe snfhr ara Since the date of your proposal for the above mentioned Policy :- (a4) saraer gatertat eaten feaorer® sirome) eter far sireict 1? (om) aon oe fe HS HH Ao we a STE? Answer Yes! or | wa sraft, faftrewat 3 aH (a) Have you ever suered from or are you suffering from :- ‘No! fen uae en ra (3, era Roar gapater ator Per? If "Yes' give details of a, TR, a Rs oH wh ee? (3) (@) @) ailment date & duration Asthma, tuberculosis or any other disease of the lungs? ‘doctor consulted (iy, eer caer a ber ee woe PRT? ‘Sear eT aT aT Be a AE Gra STA? i) High blood pressure or any disease of the heart? iy rene Fer Se, Pe hen exer here Pere ? af rae am (AFR sea), atte, Fore TAHA ar ahG a? Peptic ulcer or any disease of the stomach, liver or spleen, i. (iv) ais, qeeenieh bar ae eh hore fee? eh, a A eh (ste) ar aera eh a Be? [Any disease of kidney, prostate or urinary system? (uv) Repke, arava gorge, ata bar gest ree ser PRR? FAS, Hier SALT, GH GF, Be aM GS? Diabetes, hemia, hydrocele, Cancer or leprosy? (ui) geet, sree ar reigar are PeR? ‘par, Pet en ea at dh a ee? Paralysis or epilepsy or any disease ofthe nervous system?(iy (1) a ree er irra TER aT rT BATA STOR? (at) ra ahhh el sara ies ee ave see eat wae hr asa & sia Gade (Few. 6 aft 7) al abet ae a Gah 6. (i) sah eh er (sTeantara) 8M. (i) 3a (saw aEIRE) fe ane Gag (Rat ga) aa. a (artes are & aa) fata State your height (without shoes) cms. Your weight (with thin clothes) kgs. ‘Renisaren arorceng farts atorarcte Secret sai / fear grower wed aersta safe a: ‘Aa aN fen aor Reaeor & it Fey &s ft earee Gehan arora & sierfer one / preter at ag B= State below details of all your Policies issued and / or revived under any of the Non-medical scheme of the Corporation: Reunite erate ara era ater arrice ‘fate eae ‘ifort water tise oratera ar e/a ert ter ark ‘fer Ht Revi Name of the Div Office / Branch Policy No. ‘Sum Assured. Status of the Policy Sear after merecaraTsy Patera / act Fat & fee / For Females only :- (3) attr Sette scree satan ent 3s wera ofA, (@) Since the date of your proposal under above mentioned Poicy. (i) yet mes Tt ask at? (ii) san eh alse ret an wi? ear ost tes wt Pree et eer? ‘aay aman ag fara gan 8? Have you been menstruating regulary? Have you had any miscarriages? (i) per eer, mobi fer wafers deh here TARY ear oat wt? ‘aaa er, fare rer hor er eh a PART 8? Have you suffered or are you suffering from any disease of breast, ovaries or uterus? —_____ (a) een ser errr ten / (a) Prosar oh fh Fe (a) Pe ge rt / (58) RR ere FAP Fy (b) State the date of last menstruation —_____ (c) State the date of last delivery ——— (3) sper wen mRtee ameter wt? / (8) ger as ge TE Tah a? (6) Are you pregnant now? ‘diwo_wa / iw / DECLARATION ee 2a a te Fr Fre ge wh err co wee es a (2) eT Sg TS errr cae Fema neo er et agents ten row Teng 8 Fw Br et at Ft eH et eb Ben Rae tor er oe ey rd oe a eT renee sera oe aria AIT ge oR A cathe eae arf enter Sel rr re sre goa perch FAR Rr, PTET TTA HOE MT TST STO ST TAT a ee Feeere tits are {orden ewer aE es ge Ml ee eT aged wor £P tree der caren we maT a coer Be aR ae ees Shan ar Pr Ara ere seh & gree & rg APR oy tee ait oh aS ga a ore ert rare ate wher i: a oT eT ga a STAY ang eae oa PI BRT ORS BA TA ate ae ga: a ere Re ere aN Ro Pelee er a sata ere ar RR arent a aT A Rh haf Bs Heder HR RR een eh 8a (2) wh ee TaN Gera 2 bet rae hes rr en me arg eT eT & aT KE, eT AT ATTA Fea ST A me A rae 35 ee eae A eT & aH on hae a Re we Gale eA & yw Pa A Pe aN a Pe OY TT it wer AR eS aE Ge OA Ge Gaels a: ve ef TT ae ga ede ore Ag aT a OTR ee ae ST | “3|_______ so nereby deca that te foregoing statoments and answers ore it and \Gmplete in every paricular, and agree and deciare that these statements and this declaration alongwith Proposal for Insurance cot sosed Poly shall be tne basis of contact of revival of the lapsed Policy between me and fe Inestare ‘Corporation under the leet any unite averment be contained therein the said contract shall absolutely be null and void and all moneys, Ginich shall have been paid in respect thereof shall stand forfeited to the Corporation. “And further declare that if between the date ofthis declaration and the date of revival of the Policy () any change Ty ‘occupation aren adverse crcumstances connected with my financial position or the general hea, of myset or Te ‘of any member of my eran Gowurs or (i).& Proposal for assurance or any application for revival of @ Policy on My lie made to any Office of the cerpration ie Pending or has been withdrawn or dropped, deferred or declined or accepted at 2 increased premium or subject Corporation is Fme'oiner than as proposed. | shal forthwith intimate the same to the Corporation in. wing 19 reconsider the 10.2 en Oral ofthe Policy, Any omission on my part to do so shal render the revival absolutely null and void and ‘all moneys, ‘which shall have been paid in respect thereof shall stand forfeited to the Corporation. ‘ferifect €I Dated at eis on the ‘afta! ATe Day of ad 200 -epettererdt waren / ret 35 eR’ Signature oF Witness oA ee eS eee seer anf cer / Swern en a eee a ae ‘cull inavehd tones STA STE a aaa asernsT ape a TA ee FS wH PTA signature of Thumb Impression ofthe Life Assured eer ee nh er RA eee eae eA ee ART eT aE AT A aie werk A wd eee ING ETS TA HAT ea A AYP eRe TIF egg sre ee eT RA TH a wT Ph Ae wh TA ee Fe A NH AR eT Same sh eh ec ah re er a he gah eR a ee TT AY aE wT RC «tin this form the anewer tothe questions andior signature ofthe Life Assured are given in vernacular then the bie Assured Thin i erro ir his own handweting above his own signature that all questions were explained to him and that his replias ‘were given after fully and properly understanding the same’. en ara ets wah BA athe es A eT TTT 1 Sree fr era HE A HAY a. ag shoe wel acer a eT TA a A emer ater eer 4A ea wt are eT a A re rewanaons sould be made bythe prson ing ne fr gwen fey & hes a le | sheoreseefen car / sheoresct ar eat "I hereby declare that | have fully explained the above ‘nite tat ciseeary eae, quale tae ie (anid ‘and have truthfully recorded the answers given by the Life Assured’. waren /eeenee [Signature 2. Par ar Pee ait a / aR eR FANE @ = ‘re re er are a aaa TAR PA aT incase the life Assured is iterate: Feeacnence vs (ARE) BNET RR FAT fatter siren sirarem ee asers rer aA SET St Safa arama Se sta aT areata es PT seen arr, ot ermal iar er PHP shoes wT TE arte ge PAL HTT ETAT PA HARTY TATE 8 eho ce HE Bet THES. SSRI SH BM TAT GACH ST. ‘es agd on Pre ah OA wR ea, Reh goers, FOREN a TG fray ater a ea oe eat Sen a week ae PS eer 1a, a TA RY a arg ar 8 otk Me TERT She se cheer et TR meted Saeed ah Sek aaa Get a8 ven aE TT SOS te tic aeuesacunicgmded ote cone oe gs oH Fe aT ty a person of standing whose identity can easly be established, “thereby deciare that | have explained the contents ‘but unconnected with the Corporation and this declaration ‘should of this form to the Life Assured in sessnsnne be made by him: (language) and that | have read out to the Life Assured the answers to the questions dictated by the Life Assured Shoorecafer ser / Sheep 1 and thatthe life Assured has afixed his thumb impression ‘nro clanny =e aa 7 ee eee ener Jot to shor MY ‘understanding the contents thereot.” Sear eres See Fare ST GA oe Sore mT eS oT. fea gamer argh orem & fa sith ste & Ae TET Note. incase of dispute in respect ol iterpetation of tnms the English version sal stand val eit aR] Signature APPL OF, 50000-32016 ane