BAY NG mire 8 Abas Height 118 ems. Name: Nayab Ahemd Shaikh Gulab Weight 5°7" Kgs Date of Birth:02/11/1991 Gender: Male BrVe(Mandatory) Personal History: Smoking: Yes. Nov ‘Tobacco Products: ‘YesD Moy ‘Alcohol: Yes Now Allergies: Yes. No Permanent / Partial disability (f any): Yes Nov Impaired sight/Colour vision defects (if any): Yes) Nov Ifyou wear eye glasses / lenses mention power - Left eye: Right eye: T. Have you ever been treated or diagnosed for any of the following: spree Yes. Nov High Blood Pressure: riegn Ge Heart Disease: Yeen ov ‘Asthma: Yes Nov ‘Lung Disease: Yes Now Cancer: yest Nov Kidney Disease: + Yes 1 Wo Mental Disorder: yest Now Hepatitis or Liver disorder: Yes Nov Zin the last 6 months have you consulted a physician or currently receiving any medical treatment, advise for any condition (other than minor impairment such as cold | yegn Nov or fu) In the past 2 years have you ever had any Hiness, injury, surgical operation, received tweatment for any ailment for a continuous period of more than 2 weeks or been confined in a hospital, clinie or similar institution for any condition (other than minor impairment such as cold or fu), Yes Nov 4, Have you oF your spouse received or expect to receive any medical advise, counseling of treatment in connection with sexually transmitted disease, AIDS, AIDS Related ‘Complex or any other AIDS related condition, or had a blood test for antibodies tothe | ¥es 0 Nov AIDS virus (HIV test) ‘5, Have you ever been advised not to travel by any mode of transport due to medical or | yogi. Nov health reasons? 6. FEMALE ONLY: Are you pregnant? If "Yes", please state the expected date of delivery, cy Yes Noo a) Have you had or advised to undergo any of the following tests or investigations in| the past 12 months. If*Yes" please V which of the following “Blood tests (X-ray 0USG UECG 1 Biopsy O Endoscopy Others : tere nee Reason for tests: ‘7 b) Were there any abnormalities found in any of the tests conducted Yes Nov 8. Present state of health ;Good Good /Fair/Poor “I hereby state and confirm that all the aforesaid information is true and correct to the best of my knowledge and belief and I agree and accept that if any information is subsequently found by Tata AIG General to be false/misleading, | will be liable to be immediately disqualified or dismissed from service without any notice or liability accruing to TATA AIG General Insurance Company this regard”. Place:Mumbai Date:24/03/2016