Declaration of Good Health (DGH) Form Application/Policy no:

Full Name of Life to be insured/ assured: sanjay thapliyal

89
Height (cm): 183 cm Weight Weight Gain or Loss by 5 kgs in the past year. / No,

(Kgs): If yes (details):

Photograph
Occupation: salaried Nationality: NRI If Yes, Country of Residence indian

Contact Number: 9717249716 Indian Age: 39 Annual Income: 24 lakh Marital Status: married

Email Address:[email protected]

Please answer with ‘YES’ or ‘NO’ as applicable YES NO

1. Is there any policy which has been declined/postponed/Null & Void/agreed with special terms or a health claim admitted or rejected in any x
insurance company in India or abroad

2. Are you currently taking any medication or drugs, other than for minor conditions, (e.g. colds and flu), either prescribed or not prescribed by x
a doctor

3. Have you suffered from any illness, disorder, disability or injury during the past 5 years which has required any form of medical or
x
specialized examination (including chest x-rays, gynaecological investigations, pap smear, CT Scan, 2D echo, MRI, Biopsy, USG or blood
tests), consultation, hospitalization or surgery?

4. Have you ever suffered from, or do you now suffer from or been advised treatment for:

a) Diseases of the circulatory system (e.g. heart trouble,rheumatic fever, high blood pressure, diseases of the arteries and veins etc)? x
x
b) Diseases of the respiratory system (e.g. tuberculosis, asthma, persistent cough, pneumonia)?

c) Diseases of the Genito-urinary system (e.g. infections of the kidneys, urinary or genital organs, renal stones, venereal disease)? x

d) Diseases of the gastro-intestinal system (e.g. digestive disorders, gastric or duodenal, ulcer, hepatitis B or other disorders of the liver,
disorders of the gall bladder)? x

e) Diseases of the nervous system or mental disorders (e.g. epilepsy fits or fainting attacks, frequent headaches, nervous breakdown, strokes,
paralysis)? x

f) Diabetes, cancer or any diseases of the blood, glands, spleen, ears, eyes or skin? x

g) Unexplained night-sweats and/or loss of weight, persistent fever, chronic or recurrent diarrhoea, unexplained infections or swollen glands, x
HIV/AIDS or related complications?

h) Any Physical impairments or deformities? x

i) Any other diseases or ailments not mentioned above? x

5. Is any surgery planned or are you currently aware or have been advised, that you may need to seek medical advice within the near future? x

6. Have you ever been or currently being investigated, chargesheeted, prosecuted or convicted or acquitted or having pending charges in
x
respect of any criminal/civil offences in any court of law in India or abroad? If Yes, give details

7. Whether the Life to be Insured/Proposer/Nominee(s)/Appointee(s) is/are Politically Exposed Person(s)*? x

If Yes, give details

8. Were you ever hospitalized for Covid-19 infection or its complication or do you have any ongoing complications related to Covid-19 Infection? x
If Yes, then whether you were hospitalized or its complication to Covid-19 Infection

If Any of the above questions are answered as Yes then provide detail
Mktg/CS/DGH/Version 10/August 2023

Dehradun Date: D D M M Y Y Y Y
Place:

Signature of Life to be Insured/Assured Name of the Witness Address of the Witness Signature of the Witness

CIN: U66010MH2001PLC167089
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 I confirm that I am presently in Good health & hereby declare that the foregoing statements and answers are full complete and true. I agree that they shall be the basis of revival of
my above contract of assurance and the Reliance Nippon Life Insurance Company shall not be liable for any claim on account of illness injury or death the cause of which was known
prior to approval of my request for revival of the contract of assurance and withheld or concealed in the above statements. I authorize any physician nurse hospital official or employee
to disclose to the Reliance Nippon Life Insurance Company any and all information regarding my medical history.

If signature is in vernacular, please complete the following declaration: I have explained the contents of this form to the life to be insured and endeavoured to ensure that the contents
have been fully understood. I have accurately recorded the responses to the information sought in the form and I have read the responses back and confirmed that they are correct.

sanjay thapliyal Dehradun

Name of the Declarant Address of the Declarant Signature of the Declarant

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Customer Acknowledgement

We acknowledge the receipt of Declaration of Good Health for your Reliance Nippon Life Insurance Policy No.

on: D D M M Y Y Y Y Your Service Request Number is

Signature Branch Stamp

Mktg/CS/DGH/Version 10/August 2023

Name of the CCE: F I R S T M I D D L E L A S T

Kindly note that you can check the status of your Service request any time at https://customer reliancenipponlife.com/customer/ or call our toll free number 1800-102-1010
between 9 am to 6 pm, Monday to Saturday

CIN: U66010MH2001PLC167089
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