Scribd
Upload
114 views

Declaration of Good Health Form - With Covid Q

1) This document contains a declaration of good health form from an applicant seeking life insurance. 2) The form collects personal details of the applicant like name, occupation, contact details, health details, lifestyle habits, and travel history in light of COVID-19. 3) The applicant declares that all information provided is true and complete, and understands that failure to disclose material facts could invalidate any policy issued.

Uploaded by

Rajnish Yadav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
114 views

Declaration of Good Health Form - With Covid Q

1) This document contains a declaration of good health form from an applicant seeking life insurance. 2) The form collects personal details of the applicant like name, occupation, contact details, health details, lifestyle habits, and travel history in light of COVID-19. 3) The applicant declares that all information provided is true and complete, and understands that failure to disclose material facts could invalidate any policy issued.

Uploaded by

Rajnish Yadav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

IRDA REGN. NO.

142

Declaration of Good Health Form


Kindly answer all questions. In case additional space is required, please attach separate sheet of paper to this form.

Policy No.: Application No.:

I. DETAILS OF THE LIFE ASSURED:


Name of the Life Assured/Life to be Assured:

First Name Middle Name Surname

Occupation: Name of Employer / Business: Duration of Service (in years):


Landline No.: Mobile No.:
Are you a resident of jurisdiction outside India Yes No
(If the answer to the above question is ‘Yes', kindly fill FATCA/ CRS Form)
Country of Residence

Il. HEALTH & LIFESTYLE DETAILS


Answer the following questions in YE6 or NO. (If answer to any questions below is YES, please provide details / treatment report (current or past).
Provide relevant questionnaire for hazardous occupations (required when job profile or occupation is changed and is hazardous)

Height: Cm Weight: kg YES NO

1 Are you at present in Good Health?


2 Do you have any physical deformity / Handicap or congenital defect/abnormality?
3 During the last five years, have you consulted a doctor or have been advised to undergo any
medical investigation or treatment for any medical condition (other than minor cough, cold or flu),
or had a surgery or been hospitalized?
4 Have you ever been diagnosed with, treated for, or advised to seek treatment from any of the
following condition?
Please use ✓ to indicate which condition(s)
(a) Diabetes / Raised Blood sugar, High Blood Pressure / Hypertension, Heart disease, Chest pain,
Palpitation, Heart murmur, Heart Attack, Rheumatic Fever, High cholesterol, Disorder of the Heart or
blood vessels or undergone heart surgery
(b) Stroke, Epilepsy, Fits, Black-outs, Roma, Paralysis, Multiple Sclerosis Brain Hemorrhage, Any disease
of the Brain, Nervous System, Disease of Kidney, Renal Calculi, Bladder or Urinary Tract, reproductive
organs, Disorder of the Eye, Ear, Nose, Throat, Asthma, Tuberculosis, Bronchitis, other lungs and
respiratory system
(c) Tumor, Cancer, Leukemia, Lymphoma, Cyst, Undergone chemotherapy or radiotherapy, Anemia,
Hemophilia, Thalassemia or any other disorder of the blood, Gout, Arthritis, Back / Neck / Joint Pain,
Slip Disc and other musculoskeletal disorder, any disorder of the digestive system such as Ulcer,
Colitis or disease of the liver of pancreas. Goitre/Thyroid/Other Endocrine or gland diseases, Depression,
Schizophrenia or any Mental Disorders / psychiatric ailment, Skin disease or disorders, Liver or
Gall Bladder problems / Jaundice / Hepatitis
5 Are you currently taking, or have you previously taken, any medication or treatment for a continuous
period of more than 10 days for any condition, other than for minor coughs, cold, flu, typhoid?
Were you or your spouse ever tested positive for Hepatitis B or C, HIV, AIDS or other sexually
transmitted disease
7 Do you consume alcohol or tobacco or smoke or have any habit for drugs or narcotics?
8 For Female Applicants Only:
(a) Are you Pregnant? If yes, please mention how many weeks:
(b) Have you suffered from any gynecological problem or illness related to breasts, uterus or ovary?
(c) Have you undergone or been advised to undergo Mammogram, biopsy, or operation of breast,
uterus or any other gynecological test or test related to irregular menstruation.
Star Union Dai-ichi Life Insurance Company Limited
Registered O0ice: Star Union Dai-ichi Life Insurance Company Limited, 11th Floor Vishwaroop I.T. Park, Plot No. 34, 35 & 38, Sector 30A of IIP. Vashi, Navi Mumbai - 400 703.
@: 18002668833 (Toll tree) / 022-39546300 (landline) - 8:00 am to 8:00 pm (Mon - Sat) .
Emai|: customercare@sudIife. in | Website: www.sudIife.in | IRDAI Regn. No. 142 | C.LNo. U66010MH2007PLC174472
SUD/May-2016/DGH/ver2 Trademark used under |license from respective owners.
Declaration of Good Health Form
SUD Life COVID-19 Exposure Questionnaire

1. Have you ever been tested positive for novel corona virus, or quarantined or in contact/cohabitation with any person who has been tested
positive/quarantined or symptomatic for COVID 19. If yes, please provide details

Yes No

-----------------------------------------------------------------------------------------------------------------------------------------------------------------

2. Have you travelled in and/or out of the country 15 days prior to the Declaration of Good Health Form signing date or are you planning to
travel in and/or of the country in the next 3 months.. If yes ,please provide details

Yes No
Please provide your travel history over the past 15 days prior to the Good health declaration signing date:

Country City Date Arrived Date Departed

Please detail your intended future plans for next 3 months:


Country City Tentative Travel Intended Duration Of Stay
Date/Month/Year

3. Have you been advised to be tested to rule in, or rule out, a diagnosis of novel coronavirus (COVID-19)? Or, are you awaiting the result of a
test which has already been submitted for the novel corona virus (COVID-19)? If yes, give details

Yes No
. ______________________________________________________

Declaration of the Life to be Assured / Proposer (in case of Minor Life to be Assured) / Decleretion of the Life Assured / Proposer (in cese at Minor Life Assured):

I do hereby, declare that the answers and statements made on


this health declaration are full, complete and true in every particular and agree and declare that these statements and this declaration along with the
proposal for insurance will form basis of the contract. All material facts, being facts, which may influence the assessment of this risk, have been
disclosed in this health declaration. I understand that failure to make such disclosure shall render the contract null and void. I/We understand that the
Company is not able to offer any tax advice on GRS/ FATCA or its impact. I/ We shall seek advice from professional tax advisor. I /We further agree to
submit a new form within 30 days it any information or certification on this term becomes incorrect. I/We agree that as may be required by domestic
regulators/tax authorities the Company may also be required to report, reportable details to CBDT or close or suspend my account.

Dated at on the day of 20

Signature of Witness:

Name of Witness:
Signature / Thumb Impression of the Life Assured / Proposer
Address ot Witness:

Vernacular Declaration of the Life to be Assured / 9roposer (in case of Minor Life to be Assured) / Vernacular Declaration of the Life Assured / Proposer (in case of Minor Lile Assured) •

hereby declare that I have explained the contents of the proposal form to the Lite Assured / Life to be

Assured in language and I have read out the answers to the questions dictated to me and that the Life Assured / Life to be
Assured has put his signature /thumb impression on the proposal form after fully understanding the contents thereof.

Dated at on the day of 20

Signature of Witness:

Name ot Witness:
Signature / Thumb Impression of the Life Assured / Proposer
Address of Witness:

You might also like