STATEMENT OF GOOD HEALTH –

SPECIAL REINSTATEMENT OFFER

SPECIAL REINSTATEMENT OFFER POLICY # ____________________________ WITH SAGICOR

LIFE INC/ SAGICOR LIFE (EASTERN CARIBBEAN) LTD/SAGICOR LIFE INSURANCE TRINIDAD &

TOBAGO LIMITED ON THE LIFE OF: ____________________________________________________

Since the date of the last Medical Exam or Non-Medical Questionnaire the insured: Yes No

(1) Has the Insured continued in good health,

(2) Has the Insured made an application for insurance which has been declined, postponed or
modified,
(3) Is there any application(s) for insurance on the Insured pending in any other company at the
present time,

(4) Has the Insured visited a doctor, been diagnosed with any health-related illness, had a
change in medication or undergone any form of medical testing, eg. CT Scan, MRI, X-Ray,
ultrasound, mammogram, pap smear, histology, blood test, or clinical evaluation?

(5) Has the Insured been advised to have any diagnostic test, hospitalization, or surgery which
was NOT completed,
(6) Has the Insured had any symptoms or complaints for which he/she have not yet consulted a
doctor.

(7) Has the Insured been under observation or taken treatment, including alternative therapy,
herbal or special diet

Details of any "Yes" answers given to questions 2 to 7 above in the space provided.

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LAW ENFORCEMENT HISTORY
1. Has the Proposed Insured in the past 24 months had a Driver’s Licence revoked or
suspended, or been convicted of 2 or more driving violations, or been convicted of a
violation for driving while intoxicated or under the influence, or for driving with Yes No

impaired ability because of the use of alcohol and/or drugs?

2. Is the Proposed Insured currently in a Prison or Correctional facility due to a criminal

conviction? Yes No

3. Has the Proposed Insured been charged with or convicted of a crime during the past Yes No
5 years?
 Details of any “Yes” answers given above:

_______________________________________________________________________________________________________

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The Proposed Insured (and the Applicant if other than the Proposed Insured) represent that the foregoing statements
are true and complete and that all exceptions have been stated.

Dated at …………………...………….this…………………day of …………………………………..20………….……

Witness Signature Witness Name (BLOCK) Signature of Policyowner

Witness Signature Witness Name (BLOCK) Signature of Life Insured

(If Life Insured is other than
Policyowner)

CS10300 – March 2023

*CS10300*