SELF DECLARATION FORM (FORM TO BE DULY FILLED IN BY EACH APPLICANT ON! PERSONAL DETAILS: 1. Name of the Person tobe insured 2. Ape in completed yeas: 3 Date of bith 5. Address: i Takephone No, 7 Fema TD: 8, Identification Document details(Phote ID Proof / Ration Card) 4 Gender PERSONAL HISTOR’ each of the person listed in the Proposal Form PARTICULARS YES7NO DETAILS “, Are youn good health and free from physicaland mental Gveases or infirmity or major complaints? B, Have youver sulfered from any ofthe Talowing diseases 7 Mees Please write Yes /No. T Any Newologeal imental or rated diseases? [Slipped disc or other spinal disorder or paralysis ofany Kind or fainting episode, blackout, ft 3 High Blood pressure, palpitation, Heat dweaes —moleding ischaemic heart dseaves, other circulatory disonders_including sheumatic fever ete Diseases of uterus, ovaries, biewt oF any oiher @/naecologal disorder 3 Tistul, Pits, Hernia, Varicose veins oe ‘© Any disease of bones, joms, APIs including Hheumatie Useases 7 Any reapiratory dseares © Any allege diseases Any dimes oF vision OF Saree ae T0_Any disease of eas or difficulty or interference with heating ee TI Any disorder ofthe Wamach, ulbs, bowel or gall Blader, Kidney te TE Cancer, maligiant gowth, boll eystor wound et TS Diablos or any urinary Grease, Ta Genta order TS Aa cerebral oF Vascular strokes oF sudden [ows OT COnSCIOUSTESS OF similar disease T6 Tuberculosis (TBY TT_AIDS/TIIV? wlated disorder ee TS Conpaial dieses (Siaee Bir) TSG) Have you ever sallerod rom dental problema? VESNO (6), yes, specify same. (6) When were you treated last for the same, 20 Any ofher complain requning specialist's consulratton or SuBET ‘or hospital treatment or investigations. TI Any other complaint or tendency that may neces such consultation or treatment in the future (B) Have younoticed sudden decrease or increase in your weightin past six months Yes / No (©) Have you visited a doctor hospital healthcare unit for evaluation or for treatment in the last 12 months if yes, 4give details: (©) Give Details ofhospitalization (Attach Copy of discharge card and Doctors consultation notes and investigations) (©) _ Past surgical detalls: Name of surgery or Body past operated Date of operation: Completely cued YES / NO, give details (Attach Copy of discharge card and Doctor's constitation notes and investigations copy) I, the undersigned, hereby declare that all the information given by me in this form is true and Tunderstand that any of these details if found watrue on correlation with my medical test oF medical examination before or after issuance of policy, will affect the coverage and payments of my health insurance claim/benefit under this Policy. Name of applicant Signature: Dat: Place: