Tobacco Consumption Questionnaire

(To be completed by Life to be Assured)

1. Contract Number
2. Application Number
3. Name of the Life to be Assured

1. Do you currently consume or have your ever consumed Tobacco in any form? YES NO
If YES, please indicate in which form
Cigarettes Beedi Cigar Pipe Smoking Waterpipe (Hookah) Smoking

Chewing Tobacco Snuff Gutka Any other form______________

2. Please specify the Quantity per Day (Number of cigarettes/beedi, pouches of Gutka or
Chewing Tobacco etc.)
_____________________________________________________________________

3. Since how many years / months you have been consuming Tobacco _______ Years / months.

4. Have you ever given up Tobacco Consumption or been advised by medical YES NO
Practitioner to give up Tobacco Consumption?
If yes, then specify the reason and no. of years / months from last consumption
________________________________________________________________________

5. Do you have smoking related coughing, wheezing etc? YES NO

If YES, please provide all details
________________________________________________________________________

6. Have you ever suffered from Asthma, Breathlessness or Bronchitis? YES NO

If YES, please provide all details
________________________________________________________________________

7. Have you ever been diagnosed with any of the following? YES NO
(a)Ulcer of the Cheek
(b) Difficulty in opening the mouth wide
(c) Oral / Esophageal / lung Cancer?
(d) Any other tobacco consumption related disorder
If YES, please provide all details and attach copy of reports
________________________________________________________________________

8. Have you done any investigation like ECG, Chest X-ray in past? YES NO
If YES, please provide all details and attach copy of reports
________________________________________________________________________

I declare that the answers I have given are, to the best of my knowledge, true and that I have not
withheld any material information that may influence the assessment or acceptance of this
application. I agree that this form will constitute part of my application for life assurance and that
failure to disclose any material fact known to me may invalidate the contract.

Signature of Life to be Assured Date & Place

st
UW/Tobacco Q /Ver .1.0/1 Oct 2010