SBILife

Apne liye. Apno ke liye.

Thyroid Questionnaire (UWMO24)
(To be filled in by the Proposer/Life to be Assured)
(Answers must be in words. Strokes of the pen or dots or dashes not accepted as valid replies.)
Proposal Number 3NHOU3012
Name of the life proposed : Shanad Kuma
Date of birth : oll031to Age :54_ Years Gender: Mále/Female
(Details if any, to be provided in the space along side)
1 Since when have you noticed a swelling
in the neck? betore loyew
Is the size of swelling
Increasing a. YES ANO
2 b Decreasing b. YES NO
C.
Stationary C. YES7 NO
Do you have any discomfort due to
3
swelling? YES EO
Have you gained or lost weight during YES EO
4 the last one year?
If YES, please provide details

5 Is your appetite good? YESI NO

6 Doyou perspire excessively? YES/NO
Do youhave palpitation?
a. After moderate exercise a.
YES NO
7
b. After excitement b.
C. At rest C.

YES/ No
Date lo -o5-024
Have you been investigated for swelling T3
8 in neck? T4 5:34
If YES please provide details TSH t53o
Thyroid Scan:
Any other reports :

Have you been diagnosed as suffering

from YES NO
a.
a. Hyperthyroidism b.
b. Hypothyroidism C.
C. Thyroiditis
As Per Do ctoy aelvice
Are you taking treatment for your illness?
10
IfYES, please provide details taking a \YEZINO
mecllc'ne(Elt1 oxih IoD Mg) in last loEas
fos Thyni conto
SBILife lnsurance Co Ltd: UWMO24 Ver 1.2 Dt. 26tMarch 2022 Page 1of 2
 O
SBILife
Apne liye Apno ke liye.
Thyroid Questionnaire (UWM024)
(To be filled in by the
Proposer/Life to be Assured)

11
Have you undergone surgery? YES I,NO
If YES, please provide details
Do you have any heart related problems
12 arising from thyroid disorder? YES ( NO
If YES, please give details
Do you have any visual defects due to
13 Thyroidism? YES / NO
If YES, please give details
Have you lost significant time (no of YES /Ng
14 days) off work with this condition?
If YES, Please provide details including
dates and duration of time off work.

Declaration to be qiven by the Proposer/Life to be assured

Ideclare that the answers given above are true and to the best of my knowledge and that
Ihave not withheld any material information that may influence the assessment or
acceptance of this application.

Iagree that this form will constitute part of my application for life assurance and that
failure to disclose any material fact knownto me may invalidate the contract.
Place :

Date
Kans Shrackvner
Signature of Proposer/ Life to be assured

Vernacular Declaration in casethe Proposer has signedthe

questionnairein vernacular or Proposer is illiterate

Ihereby declare that Ihave read out and explained the contents of this questionnaire to the
Proposer in language and that he/she had understood the same
and the answers were truly and correctly recorded.
| have fully explained that this forms part of the contract and if there has been any non
disclosure of material fact, the policy may be treated as null and void.
Place
Date
Signature of personmaking the Declaration
Name of person making declaration
Address

SBILife Insurance Co Ltd: UWMO24 Ver 1.2 Dt. 26thMarch 2022 Page 2 of 2