Declaration of Good Health

Personal Details of Proposer:-

Title:- Mr/ Mrs/ Ms

Full Name (BLOCK Letters):-

Date of Birth (DD / MM / YYYY):-

Gender:- Male / Female

Address:-
City:-

State Pin Code:-

Telephone No.-with STD Code
Mobile
Email address

I declare that I am along with my proposed family members, are in good health and we do not have any physical/mental defect,
deformity or disability. Additionally I declare that I and my family members proposed for health insurance do not have any history of
Pre-existing disease, have never suffered from, not currently suffering from, any ailment or disease.

Vernacular Declaration:

Further, I hereby declare that I have fully explained the contents of the good health declaration and all other documents incidental to
availing the health insurance from Universal Sompo General Insurance Company Limited to the Proposer in the language understood
by him/her. The same have been fully understood by him/her and the replies have been recorded as per the information provided by
the Proposer and the replies have been read out to fully understood and confirmed by the Proposer.

Declarant`s Name: ……………………………………………….

Relationship with the proposer: ……………………………

Date ………………………

Place………………………

…………………………….
Signature or Thumb Impression of the proposer

Toll Free Numbers: 1800-200-5142

Landline Numbers: (022) - 39635200 (Local Charges Apply)
Fax Number: 1800-200-9134 E-mail Address: contactus@universalsompo.com. or contactclaims@universalsompo.com

USGI IRDA Registration No. 134