MAX LIFE INSURANCE COMPANY LIMITED
KIDNEY AND URINARY DISORDER QUESTIONNAIRE
Proposal No: 621895630
Life to be Insured: Vaibhav Sharma
1. Please state the precise diagnosis, if known. Kidney Stones which have been treated
2. When did symptoms first occur ? 7th October 2023
3. When was the condition first diagnosed ? 7th October 2023
4. Have you had an IVP cystoscopy or other investigation ? No
(If “Yes”, please give details including dates of ________________________________
investigations & results regarding your symptoms)
5. Regarding your symptoms
a) Please describe your symptoms Stomach Ache
b) How frequently do the symptoms occur ?
e.g., how often in last months. Last happened in October 2023 Only
c) When was the last occurrence of symptoms ? 21st October 2023
6. Have you had an operation for this condition or is an No
operation being considered ? If “Yes”, Please give
a) Full dates and full details including name of Dulet Hospital (Dr. MS Dulet) date : 7th Oct 2023
hospital and consultant/ surgeon
b) Have you experienced any symptoms following No
surgery If “Yes”, please give details ________________________________
7. Please give details of your treatment. Include names
of medication, dosage and how often taken:
a) Currently N/A
b) In the past Dicloran Injection, Glucose
8. Regarding the monitoring of your condition
a) Who is in charge of your follow -up ? N/A
b) How often do you attend for follow- up ? N/A
c) When was your last consultation ? N/A
d) If you have been discharged from follow up,
please state when ? October 23rd, 2023
9. Have you lost significant time (e.g. weeks) off works Yes
due to this condition ? 2 Weeks
If “ Yes”, please provide details including time and
duration off work.
10. Please provide any additional information on your
condition which you feel will be helpful in processing
your application.
I hereby declare and agree that the above particulars and answers are complete and true, that I have not held
back any relevant facts or details, and that the answers to questionnaire will form part of the application for the
desired insurance on my life.
Signature of Life to be Insured Date
(If the life to be insured is under 18 years, signature of Policy Owner )
Max LI - AS_05062012_VER1.2
