MAX LIFE INSURANCE COMPANY LIMITED

KIDNEY AND URINARY DISORDER QUESTIONNAIRE

Proposal No: _____________________________

Life to be Insured: ___________________________________

1. Please state the precise diagnosis, if known. ______ _________________________

2. When did symptoms first occur ? ______ _________________________

3. When was the condition first diagnosed ? ________________________________

4. Have you had an IVP cystoscopy or other investigation ? Yes / No

(If “Yes”, please give details including dates of ________________________________

investigations & results regarding your symptoms)

5. Regarding your symptoms

a) Please describe your symptoms ________________________________

b) How frequently do the symptoms occur ?

e.g., how often in last months. ________________________________

c) When was the last occurrence of symptoms ? ________________________________

6. Have you had an operation for this condition or is an Yes / No

operation being considered ? If “Yes”, Please give

a) Full dates and full details including name of _______________________________

hospital and consultant/ surgeon.

b) Have you experienced any symptoms following Yes / No

surgery If “Yes”, please give details ________________________________

7. Please give details of your treatment. Include names

of medication, dosage and how often taken:

a) Currently ________________________________

b) In the past ________________________________

8. Regarding the monitoring of your condition

a) Who is in charge of your follow -up ? ________________________________

b) How often do you attend for follow- up ? ________________________________

c) When was your last consultation ? ________________________________

d) If you have been discharged from follow up,

please state when ? ________________________________

9. Have you lost significant time (e.g. weeks) off works Yes / No

due to this condition ? ________________________________

If “ Yes”, please provide details including time and

duration off work. ________________________________

10. Please provide any additional information on your ______________________________

condition which you feel will be helpful in processing ______________________________

your application. ______________________________

I hereby declare and agree that the above particulars and answers are complete and true, that I have not held
back any relevant facts or details, and that the answers to questionnaire will form part of the application for the
desired insurance on my life.

Signature of Life to be Insured Date

(If the life to be insured is under 18 years, signature of Policy Owner )

Max LI - AS_05062012_VER1.2