(Tp, be inserted as item no. 31 (A) of proposal form for insurance cover > 20 lakhs and upto 50 lakhs) DECLARATION BY THE PROPONENT AND TO BE COUNTERSIGNED BY THE HEAD OF OFFICE Certified that | have not underwent any treatment for the diseases mentioned at items (i) to (xvi) of Point No. 29 of the Proposal Form during the last 3 years and | also certify that | have not claimed any medical reimbursement claims in c/w any of the disease mentioned at items () to (xvi) of point 29 of the Proposal Form (except Hypertension and Diabetes) from the Employer or from any other Medical Insurance Company/Firm during the last 3 years. Date: Certified that as per official records, no medical reimbursement claim of ‘ Shri inion AMPIOYER BB sneesn on i . {indicate Name of Office) has been received or admitted in r/o diseases mentioned at items (i) to (xvii) (except Hypertension and Diabetes) of Point No. 29 of the Proposal Form during the last 3 years. Date (Certification by Head of Office) With Official Seal (To be inserted as item no. 29 (f) of proposal form for insurance cover > 20 lakhs and upto 50 lakhs) MEDICAL UNDERWRITING NORMS FOR INSURANCE MORE THAN 20 LAKHS AND UPTO 50 LAKHS a) Age upto 35 years ECG, Routine Urine Analysis, SBT 13, Hb% b) Age between 36 yrs to 45 yrs : ECG, Routine Urine Analysis, SBT 13, CTMT, Hemogram c) Age between 46 yrs to 55 yrs : ECG, Routine Urine Analysis, S8T 13, CTMT, Hemogram, Hb Alc d) 56 yrs & above (for revival cases) : ECG, Routine Urine Analysis, SBT 13, CTMT, Hemogram, Hb Alc & Xray of Chest (Detoils of tests included under SBT 13, Hemogram and RUA is attached)(To be inserted as item no. 7 (A) of proposal form for insurance cover > 20 lakhs and upto 0 lakhs) Gross Salary Drawn during the last 3 months : i) Rs, ii) Rs. iil) Rs. FINANCIAL ING. IN Rt 10 LAKHS AND UP’ ‘The maximum Sum Assured will be restricted as under: a) Till 40 years of age at Entry Sum Assured should be 10 times Annual income subject to total aggregate or maximum of Rs. 50 lakhs b) For 41 years and above Sum Assured should be 7 times Annual Income subject to total aggregate or maximum of Rs. 50 lakhs