Arthritis Questionnaire

Name Of Proposed Insured: ............................................................................................................................

Policy no.: ....................................................................................... Dated:................................................

1) Which form of arthritis do you suffer from? E.g. Rheumatoid arthritis, osteoarthritis, etc
.......................................................................................................................................................

2) When was this condition first diagnosed?

........................................................................................................................................................

3) How would you describe the current condition? ( mild/ moderate/ severe)
(Improving/ progressively / worsening)
...........................................................................................................................................................
4) a) What is the current extent of symptoms? Please specify the joints where you get the Maximum
symptoms.
...........................................................................................................................................................
(b) Are your activities restricted in any way? If Yes, please provide details.

.........................................................................................................................................................
(c)Do you use a walking stick or other mobility aids? If Yes, please provide details.

…………………………………………………………………………….....................................
(d)What treatment has or is currently being prescribed for this condition?
Please state name/type and dosage.
………………………………………………………………………….....................................
(e) Are you taking corticosteroids for the condition?
………………………………………………………………….................................................

5) a)Have you been advised to have, or have you had a joint replacement or any other surgery or
intervention? If yes, please state details.
Yes No If Yes, please provide details

………………………………………………
………………………………………………

Tata AIA Life Insurance Company Limited

.(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Oct/218
b) Have you lost significant time (eg weeks) off work with this condition?

Yes No If Yes, please provide details

………………………………………………
………………………………………………

6) Which investigations were done? ( Eg, X –rays, MRI scans, CT scan, blood tests, Full medical
exam, other etc). Please provide copy of medicals report accordingly.
...........................................................................................................................................................

I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.

Signature of Proposed insured:______________________ Date:____________________

Signature of Applicant:______________________ Date:____________________

(If applicant is different from the proposed insured)

VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.

I__________________ holding ______________(ID card type) with number __________(ID card

number) hereby declare that I have explained the contents of this declaration to the Proposed
Insured/Applicant in ________________ language and that the Proposed Insured/Applicant has affixed
his/her signature/thumb impression after fully understanding the contents thereof.

________________________________ _____________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature

Tata AIA Life Insurance Company Limited

.(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Oct/218