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PSRF598813071602
Comp/June/Int/4689

Personal Statement of Health for Revival of Policy

Policy Number: _____________________________ Branch:

Name of the Life Assured: F I R S T N A M E M I D D L E N A M E S U R N A M E

Name of the Proposer: F I R S T N A M E M I D D L E N A M E S U R N A M E
(if different from the Policyholder)

Marital Status: Single Married Divorced Widow / Widower

Address:

Reason for Lapse:

Present Occupation: Gross Annual Income in `:

(From all sources) (figures in digits)

Type of Industry: Does your job involve hazardous activity? Yes No

Name and address of the present employer OR

business premises if self-employed:

Please provide the information required below pertaining to the Life Assured from the date of policy application till date.

A . Personal health details:

1. Have you suffered from any of the following conditions mentioned below ? Yes No Mention details, as applicable

a) Cardiovascular disorders such as chest pain, heart attack, arrhythmia, palpitations,

giddiness, anxiety, Cardiomyopathy, Hypertension/High Blood pressure, Coronary artery
bypass grafting (CABG), Angioplasty (PTCA ) or any other heart related conditions.
b) Respiratory disorders such as bronchitis, asthma, wheezing, pneumonia, tuberculosis,
anyother disease of chest and lungs.
c) Gastrointestinal system disorders- Gastritis, ulcer, hernia, disease of liver, pancreas, spleen,
stomach, disease of short and long intestine, Jaundice, etc.
d) Urinary system disorders such as disorder related to kidney, urinary bladder, ureter, prostate,
hydrocele, etc.

e) Nervous system disorders such as paresis, transient ischaemic attack, paralysis, Stroke,
Alzheimer, Parkinson’s, meningitis, multiple sclerosis, epilepsy, blackouts, migraine or any
other disorder or tumor of brain, spinal cord or nerves. Mental disorders such as major or minor
depression, Obsessive Complusive Disorder, addictions, uncured insomnia, anxiety or nervous
breakdowns.
f) Ear, Nose, Throat, Mouth system disorders such as ear discharge, nose bleeding, deafness,
blindness, hearing loss, etc. Skin disorders such as varicose veins, psoriasis, eczema, moles or
dermatitis. Musculoskeletal disorder such as Arthritis, gout, rheumatism, disc prolapse,
fracture history, Osteoporosis, back pain, disorders of bones or any other conditions.

g) Diabetes/ elevated blood sugar/sugar, ketone, proteinuria or diabetes related complications

such as diabetic coma or any other hormonal diseases related to Thyroid gland or any other
hormonal imbalance.
h) Cancer or tumour or benign tumour or cyst, lump, enlargement of lymph nodes or any other
growth.
i) Blood disorders such as anemia, haemophilia, thalassaemia, leukaemia or any other blood
disorder or suffered from dengue, swine flu or encephalitis.

2. Have you undergone any lab test including HIV & HBsAg, radiological test or any special
investigation test such as ECG, MRI, CTMT, etc. or suffered from any accidents, injury, major
burns or advised hospitalisation?

3. Do you have any recurrent medical condition, physical disability, deformity, any illness or
injury that has kept you away from work?

4. Have you or your spouse been tested positive for HIV / AIDS or Hepatitis B or C or have been
tested / treated for other sexually transmitted diseases OR are you awaiting the results of such
a test?

5. Are you currently in good health?

6. Female Specific health disorders

a) Have you had any disease of uterus, breast, cervix, ovaries or have undergone hysterectomy?
b) Have you undergone PAP smear, mammogram or USG pelvis?
c) Are you currently pregnant? If yes, how many weeks? ______________

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 B. Family medical history:
Has any death or illness occurred in your family (parents or siblings)? If yes, then mention
the age at death and cause of death / nature of illness.
Indicate by ticking in Mention details, as applicable
relevant box
C. Other personal details: *Please attach a separate sheet in
Yes No case the space is inadequate
1. Provide us the exact details of existing insurance with HDFC Life (both lapsed and in-force)

2. Do you have any current active insurance cover or has any of your life insurance / health
insurance / rider been accepted with extra premium, accepted on other special terms, Reason: _________________________
postponed, declined or not taken up by you?
3. Have you submitted any simultaneous applications for insurance to any of our offices or Proposal / Policy No.: _______________
another insurance company which is still pending OR are you likely to revive any lapsed Sum assured: _____________________
policies? Company Name: ___________________
4 . Have you ever made any claims for hospitalisation or surgery or critical illness benefit under
this policy or any other health insurance policy from any other company?
5. Do you take part in any adventurous sports or hobbies? (like paragliding, mountaineering,
deep sea diving , motor racing, bungee jumping, etc.)?
6. Have you ever resided overseas for more than 6 months or do you intend to travel overseas Past Travel: _____________________
in the next 6 months and reside for more than 2 months? Future Travel: ____________________
7. Are you an NRI ?

7. a. Height- Feet inches OR Centimeters b. Weight - ( Kgs)

8. Please give the habits details as follows :

Substance consumed Do you consume? If yes, please provide details Quantity

Alcohol Beer Wine Spirit Others Units* / Week

*(1 unit = 330 ml of beer / 30 ml of spirits / Yes No
125 ml of wine)

Tobacco Cigars Cigarette Bidi

*(1 unit equivalent to 1 cigar / 1 cigarette / 1 Yes No Units * /Day
bidi. If chewing tobacco, please specify how Chewing Tobacco Others
many grams per day .)

Addictive or intoxicating drugs (example Ganja, Hashish, Heroin, Cocaine, Marijuana, Charas, etc.) Yes No

Declaration from the Life Assured:

I hereby declare that all the information given by me/on my behalf is true and I have not withheld any material fact within my knowledge. I agree that the
information provided in this declaration along with my proposal for insurance shall be the basis of contract of revival of the lapsed policy. I also agree and
understand that the application for revival of the policy will be considered by the Company at its sole discretion. I declare that, I do not have any history of
conviction under any criminal proceedings in India or abroad. SIGN HERE

DD/MM/YYYY
Date : ________________________

Signature of the Life Assured

Place : ________________________ ( To be signed by the Policyholder if the
Life Assured is a minor )

Declaration from the Policyholder (If Policyholder is different from the Life Assured ):
I hereby declare that all the information given by me/on my behalf is true and I have not withheld any material fact within my knowledge. I agree that the
information provided in this declaration along with my proposal for insurance shall be the basis of contract of revival of the lapsed policy. I also agree and
understand that the application for revival of the policy will be considered by the Company at its sole discretion. I declare that, the Life Assured does not have
any history of conviction under any criminal proceedings in India or abroad. SIGN HERE
DD/MM/YYYY
Date : ________________________

Place : ________________________ Signature of the Policyholder

Declaration made by third party where the Policyholder has affixed his/ her thumb impression/ has signed in vernacular:
The Policyholder has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this
application form has been explained to the Policyholder in __________________ language and have truthfully recorded the answers provided to me. I
further declare that the Policyholder has signed/affixed his/her thumb impression in my presence.
SIGN HERE
Name: ________________________________________________________

Date: DD/MM/YYYY __________________ Place: _______________________________

Signature of the Third Person
Address: _________________________________________________________________________________

NOTE

With reference to recent regulatory changes, please submit PAN or Form 60 (if you do not have a PAN) with HDFC Life with immediate effect. Pls update via
My Account/[email protected]/18602679999/HDFC Life branch. Ignore if submitted.

HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com

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