Life Insurance

Aditya Birla Sun Life Insurance Company Ltd.

Medical Examiner's Report

Part I (Form To Be Used For Ages 18 and above)

Application No: Insurance Advisor No.:

Name of the Insurance Advisor: Branch:
Name of the Life to be insured Mr/Mrs/Ms.:
Date of Examination: D D M M Y Y Y Y Date of Birth: D D M M Y Y Y Y Sex: M F

Place of examination: Clinic Client's residence ABSLI's Medical Examiners Code:

Identification: Proposed Insured must show acceptable form of identification (Any of the below)

Passport Driving Licence Aadhaar Card PAN Other Picture/Signature I.D (e.g. Voter's card)

1. Family History:

Living Dead
Age State of health Age at death Cause of death Year of death
Father
Mother
Brothers
Sisters
Please provide complete details for all the questions answered "YES", mentioning dates, reasons, diagnosis, treatment results, with name and
address of the attending physician.
Yes / No Details of affirmative replies

2. Have any of the above had tuberculosis, heart ailment,

high blood pressure, cancer, diabetes, mental
disorder or hereditary disorder?
3. Are you on diet or any other medicine prescribed by a
doctor?
4. Within the past five years, have you:
(i) Circle appropriate items (ii) *fill questionnaire
a) Consulted any doctor or other health practitioner?
b) Submitted ECG, X-rays, blood test or other tests?
c) Attended or been admitted to any hospital or other
medical facility?
5. Have you ever had or sought advice for
(i) Circle appropriate items (ii) *fill questionnaire
a) Chest pain, high blood pressure, stroke, heart attack,
heart murmur or other heart disorder?
b) *Asthma, chronic cough, pneumonia, shortness of
breath, T.B or any other respiratory or lung disorder?
c) *Diabetes or sugar in the urine?
d) Protein (albumin), blood or pus in the urine, sexually
transmitted disease or venereal disease?
e) *Ulcer, colitis, chronic diarrhoea, hepatitis or
jaundice or other liver or digestive disorder?
f) Cancer, tumor, thyroid disorder, enlarged glands or
enlarged lymph nodes?
g) Anemia, bleeding or blood disorder?
h) *Dizzy or fainting spells, epilepsy, paralysis, nervous
or mental/emotional disorder?
i) Urine, kidney, bladder, reproductive organ or
prostate disorder?
j) Arthritis, gout or joint pain, muscle, bone fracture
or disorder?
 Yes / No Details of affirmative replies
k) Any other illness, surgery or injury?
l) Acquired lmmune Deficiency Syndrome' (AIDS) or
AIDS related complex (ARC)?
m) A test indicating the presence of HIV A(IDS virus)?
6. Do you have any bodily deformities?
If YES, state nature and extent of deformity.
7. Do you have any health symptoms or complaints for
which a physician has not been consulted or treatment
received?
For example, persistent fever, unexplained weight loss,
loss of appetite, pain swelling etc. If YES, give details.
8. a) Indicate your average weekly consumption of
alcohol _________________
b) Have you ever been advised to stop drinking
aloohol or to drink less?
9. For female lives:
a) Are you pregnant? 'YES' {Number of weeks:
________________)
b) Have you had, or do you have, any complications of
pregnancy at present or in the past?
c) Have you had, or do you have, any gynecological
problem?

I_____________________________________________________________________________________________, declare that I have made no

statement to the medical examiner, agent, or any person connected with the Company which in any way qualifies or modifies the above answers which I
have read and certify to be full and true to the best of my knowledge and belief.
Signed at ______________________________________________ Date: D D M M Y Y Y Y

Signature of Life Insured: _____________________________________ Medical Examiner’s Signature ________________________________________

AUTHORIZATION
Application No.:
I hereby authorize any physician, hospital, clinic, insurance company or other organization, institution or person, that has any record or knowledge of
me or my health, to give to Aditya Birla Sun Life Insurance Company Limited any and all information about me with reference to my health and
medical history and any hospitalisation, advice, diagnosis, treatment, disease or ailment. I also consent to a personal investigation. A photographic copy
of this authorization shall be valid as the original.

Date: D D M M Y Y Y Y
Witness Signature in full of person proposed for insurance
Part II (Urine analysis is a part of the Medical Examiner's Report and should be done for all clients.)
1. Have you attended the person to be insured professionally? If YES, for what and when? Yes No
2. a) Height: cms Weight: Kgs. If weight changed within 12 months Kgs. Gained Lost Constant
Reason: b) Chest: Exhale cms. Inhale cms.
c) Girth of Abdomen at naval level cms.
3. Cardiovascular System:
a) Blood Pressure. Initial Readings__________________If initial reading exceeds 140/90 record 3 successive Blood Pressure Readings

Systolic
Diastolic (Cessation of sound)

b) Do you detect: (Tick appropriate items)

Yes No
heart enlargement?
a murmur or abnormal sounds? (If Yes complete Q.10) a carotid, abdominal or femoral bruit?
xanthelasma, xantomata or arcus senilis?
abnormal femoral or pedal pulses?

c) Pulse rate: /min. Regular Irregular/If irregular, describe irregularity before and aer exercise (ten full knee bends in one minute).
Before exercise Increase Decrease Disappears / Aer exercise Increase Decrease Disappears
4. Do you detect any abnormality of the: (circle appropriate items) Yes No
a) oral cavity, eyes, ears, nose, throat, skin, lymph nodes or thyroid glands?
b) thorax or lungs (deformity, rales, etc.)?
c) abdomen: mass splenomegaly, hepatomegaly or any stigmata of liver disease?
d) nervous system: mentality, personality, reflexes?
e) musculoskeletal system, extremities, joints, spine?
f) Other system: Genitourinary, Gynec. etc?
 5. Is there Yes No
a) edema of the ankles?
b) any surgical scar on abdomen, thorax or elsewhere?
c) hernia? If so describe (Reducible or Irreducible)

6. Is the applicant presently a smoker? Yes No If 'YES' number per day:

Cigarettes/Bidis Tobacco chewed Other tobacco use (specify)

During adult life have smoking habits changed substantially Yes No If so, give details.
7. Urine analysis: Urine may be examined using Dipstix

Specific Gravity Albumin Sugar Blood

If there is any abnormality in the urine, history of finding of hypertension, diabetes mellitus, or any urine disease, conduct routine Urine analysis
at ABSLI's authorized laboratory.

8. Do you consider from your examination that the applicant is Healthy Otherwise (Please clarify)

9. Have you observed or suspected any unusual features not noted above? Yes No if YES give details.

Give full details of questions, answered 'YES' in the space below. Identify by question no. Use a separate sheet for any additional information.

10. Complete only if murmur or abnormal sound is detected Graphic description (if desired), Optional

Indicate on diagram: Mid-Clavicular Line

Apex O
Murmur X
1st 2nd 3rd Mid-Sternal Line
Transmission

Is there a: Murmur Gallop Click

Is the murmur: a) Systolic Diastolic b) So (Grade 1-2) Moderate (Grade 3-4) Loud (Grade 5-6)

c) On standing: Unchanged Louder Soer Your impression: Innocent Orqanic (clarify)

Please mail completed report by sealed envelope to the Medical Department

At the request of agent Branch:

I Dr.

hereby certify that the Medical History was obtained and recorded by me and the applicant was medically examined by me on this date

Examiner's Signature:

Name:

Date: D D M M Y Y Y Y ABSLI's Medical Examiner Code:

Aditya Birla Sun Life Insurance Company Limited

(Formerly known as Birla Sun Life Insurance Company Limited)
Regn. No.: 109. Regd Office: One Indiabulls Centre, Tower 1,
16th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg,
Life Insurance
Elphinstone Road, Mumbai - 400013
+91 22 6723 9100 | CIN: U99999MH2000PLC128110
Aditya Birla Sun Life Insurance Company Ltd.
www.adityabirlasunlifeinsurance.com

“The Trade Logo “Aditya Birla Capital” Displayed Above Is Owned By ADITYA BIRLA MANAGEMENT CORPORATION PRIVATE LIMITED (Trademark Owner) And Used By ADITYA BIRLA SUN LIFE INSURANCE COMPANY LIMITED
(ABSLI) under the License.”