Declaration Of Good Health

For revival of lapsed policies

Branch: _________________________________________________________ _______________________________ Date: ____________________________

Policy Number: _____________________________________________________________________
Full name of the Life Assured
(IN BLOCK LETTERS) : _______________________________________________________________________________________________________________
Full name of Policy holder : _________________________________________________________________________________________________________________
(IN BLOCK LETTERS)
Telephone/ Mobile No. : _________________________________________________________ E-Mail: ____________________________________________________

Address: ________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________ Pin Code: _____________________

Answers To The Questions Should Be Based On Happenings Subsequent To Issue Of Above Mentioned Policy

(1) a) Are you currently taking or have you previously taken any medication or treatment for a continues LA PH
period of a week or more? Yes No Yes No
b) Have you ever consulted any doctor for a surgical operation or have you ever been hospitalized or advised
to undergo any medical investigation or treatment for any medical condition? Yes No Yes No
c) Did you ever have any operation accident or injury? Yes No Yes No
d) Have you had an electrocardiogram, CTMT, X-ray or screening, blood urine or stool examination or any
other pathological test? Yes No Yes No

(2) Has a proposal or an application for revival of policy on your life made to this or any office of the company or
any other insurer ever been declined / postponed / withdrawn / accepted with extra premium /revised terms Yes No Yes No

(3) Have you ever used tobacco in any form? Yes No Yes No

(4) Have you ever consumed alcohol in any form?

If yes, give details.________________________________________________________________________ Yes No Yes No

(5) Have you involved in any adventures avocation like flying, non commercial aeroplane, automobile racing,
horse riding, boat race, scuba diving? Yes No Yes No

If any of the questions is answered above as if yes then give details of ailment with date , duration and
doctors consulted.

If yes Detailed Description (LA) If yes Detailed Description (PH)

(6) a. State your height Cms Your Weight Kgs. (6) b. State your height Cms Your Weight Kgs.
(Life Assured) (PH)
(7) Are you at present in good health? Yes No Yes No

(8) For Females Only

(i) Have you been menstruating regularly? Yes No Yes No
(ii) Have you had any miscarriages? Yes No Yes No
(iii) Are you pregnant now? Yes No Yes No
(iv) Date of last Delivery.
LA PH
(9) State your annual income (Rs)

(10) a) State your Occupation

b) State your nature of duties

(11) State below details of all your policies (if any) to be revived along with this policy.

Policy No Sum Assured Year of Issue Status

31_1_2019
 1008863325

Declaration

I hereby declare that the foregoing statements and answers have been answered by me after fully understanding the questions and the same are true and complete in every
aspect and that I have not withheld or misrepresented any information and I hereby agree and declare that this declaration along with the statement made shall be the basis
of the contract of assurance between me and Bajaj Allianz Life Insurance Company and any concealment/ misrepresentation/ fraudulent misrepresentation/ averment/
assertion shall render the contract of insurance null and void in entirety. No partial enforcement of any claim shall be sought howsoever minor the concealment/
misrepresentation/ fraudulent misrepresentation/ averment/ assertion is with regards to any part of the contract. All money, which shall have been paid in respect thereof,
shall stand forfeited to the Bajaj Allianz Life Insurance Company, notwithstanding the provision of any law usage, custom or convention for the time being enforced
prohibiting any doctor, hospital and/or employer from divulging any knowledge or information concerning my health or employment on the grounds of secrecy, I my/ heirs,
executors, administrators and assignees or any other person or persons, having interest of any kind whatsoever in the policy contract issued to me, hereby agree that such
authority having such knowledge or

information, shall at any time be at liberty to divulge any such knowledge or information to the Bajaj Allianz Life Insurance Company.

Signature / Thumb impression of Proposed Insured Signature of Proposer Signature of Witness

Place Name of Witness

Date Address

Contact No.

If the answers and/or signature herein above are/is in vernacular then he/she should declare below in own handwriting that the replies were given after fully and properly
understanding the questions.

Signature of proposed insured Signature of proposer

Vernacular Declaration

Declaration by the person filling in the form (If other than the policy holder):

Declarant’s Name _________________________________________________________________________________________________________________________

Address _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

City_________________________________________State____________________________________________Pin Code____________________________________

I hereby declare that I have fully explained the above questions to the Policyholder and I have truthfully recorded the answers given by the Policyholder.

Signature of person filling up the revival form

Name __________________________________________________________________________________________________________________________________

Address _________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

City_________________________________________State____________________________________________Pin Code____________________________________

For office use only

Policy Number: ___________________________________ DOC: _____________________ SA: ____________________________ Mode: _____________

Premium: ________________________________ FUP: __________________________ No of Dues: ________ Date of Revival: ___________________________
Premiums to
To: ____________________________ Total Premium: _______________________ Interest: ________________
be paid from: _____________________________
Total Amount to be Paid Decision_________________________________________________

Name ________________________________________________________________________________________
31_1_2019

Designation___________________________________________________________________________________
Signature