DECLARATION OF GOOD HEALTH

Date: D D M M Y Y Y Y

Name of the Life Assured: Policy No.:

Client ID Contact No.(Off/Res):

Mobile No: Email ID:

Date of Birth: D D M M Y Y Y Y Height Cms Weight Kgs Gain/loss in past 1 year :

(Please tick YES or NO to each question)

1. Have you taken part, or do you have plans to take part, in any hazardous activity such as ballooning, mountain cycling, motorbike racing, boxing, Yes No
gliding, diving, horse riding, martial arts, motors racing, mountain climbing, parachuting, sailing, skiing, weight lifting, white water rafting,
wrestling and / or flying other then as a fare paying passenger on a licensed service? (you must still answer YES and give details if you take part in
a potentially hazardous activity which is not listed). if yes, please provide details in the special questionnaire which your advisor will give you

2. Are you currently or do you intend to live or travel outside of india for more then 6 months in a financial year? if yes, please provide full details of Yes No
countries to be visited and the purpose of visit and duration_________________________________________________________________________
___________________________________________________________________________________________________________________________

3. Have you smoked or used any form of tabacco in the past 12 months? if yes, please indicate in which form: Yes No
Cigarettes Beedi Chewing Gutkha Any Other Quantity per day

4. Do you consume any form of alcohol ? if yes, what type? Yes No

Beer Wine Hard liquor Quantity per week

5. Are you currently taking any medication or drugs, other then minor conditions (e.g. cold and flu),either prescribed or not prescribed by a doctor, Yes No
or have you suffered from any illness, disorder, disability or injury during the past 5 years which has required any form of medical or specialized
examination (including chest X-ray gynecological investigations, pap smear, or blood tests), consultation, hospitalization
or surgery?

6. Do you have: congenital/birth defects, pain or problems in the back, spine, muscles or joint, arthritis, gout, severe injury or other physical Yes No
disability and have you been in capable of working/ attending the school during the last 2 years for more than 3 consecutive days or are you
currently in capable of working/ attending school?
Please ignore normal pregnancy.

Yes No
7. Do you suffer from or ever had any medical ailments e.g diabetes, high blood pressure, cancer, respiratory disease ( including asthma), Kidney or
liver disease, stroke, any blood disorder, heart problems?

8. Do you suffer from or ever had any medical ailments e.g. Hepatitis B or C, or tuberculosis, psychiatric disorders, depression, colitis, or any other Yes No
stomach problems, thyroid disorders, reproductive organs, HIV AIDS or a related infection?

Yes No
9. Do you suffer from or ever had any medical ailments e.g. tumor growth, prostrate disorder, disorder of skin or Lymph glands, multiple sclerosis,
epilepsy, tremor, numbness, double vision or giddiness, speech defect, paralysis?
Yes No
10. Have you ever been advised /had a surgery or any medical investigations like X-ray, Ct scan, mammogram, pap smear etc?

11. Have you ever suffered from drug/narcotics or alcohol addiction or been advised by a doctor to reduce your alcohol/ tobacco consumption? Yes No

12. In the last 3 years, have you been treated, or currently undergoing or have been advised for treatment from a doctor or specialist or undergone Yes No
any cardiological, radiology or pathological tests ( excluding routine cheak-ups)?

If you have answered yes, to any of the questions between 5 and 14 please provide the details here

Question No. For question No 5 to 14 provide complete details including health condition, date of diagnosis, treatment prescribed, name/address of
doctor-if applicable

IndiaFirst Life Insurance Company Ltd., Tel: +91 22 6165 8700 Fax: +91 22 6857 0600 Toll Free: 1800-209-8700
12th and 13th Floor, North [C] Wing, Tower 4, Nesco IT Park, Nesco Center,
Western Express Highway, Goregaon (East), Mumbai – 400063,
CIN: U66010MH2008PLC183679. E-mail: customer.first@indiafirstlife.com Website: www.indiafirstlife.com
14. For female Life to be Assured only
a . Are you pregnant at present ? Yes No If yes, duration in weeks:

b. Date of last delivery

Has the policy to be reinstated been issued at standard rates previously Yes No
If No, please mention the reason for which it was rated up.

Have you ever attended medical examination for IndiaFirst Life Insurance? Yes No
Do you have any other policy (issued or applied) with indiaFirst Life Insurance ?
if Yes, please provide the application number.

I understand and agree that the answers and statements made on this Health Declaration are full, complete and true in every particular and will form the basis of
the contract. All material facts, being facts which may influence the assessment of this risk have been disclosed in this health declaration. It being understood by
me that as per Sec 45 of the Insurance Act,1938, failure to make such disclosure renders the contract voidable at the option of the insurer. I consent

a) To IndiaFirst Life Insurance Company Ltd. seeking medical information from any doctor, employer, any physician, nurse, hospital official or employee and authorize
them to disclose to the IndiaFirst Life Insurance Company Ltd. any, and all information regarding any medical history and any matter relating to my physical or mental
health.
b) any hospital giving such information to IndiaFirst Life Insurance Company Ltd. and/or to the claims administrator or medical advisors.

Signature of policy holder and

X
Signature of the Life to be Assured
X Name and Signature of the Branch Official

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

VERNACULAR DECLARATION (to be filled if the policyholder is illiterate/signed in a Vernacular language

I do hereby state that I have read out and explained the contents of the form to the policyholder in _________ language and he/she have understood the same. I
declare that whatever I have stated herein above is true and correct to the best of my knowledge and belief. The policyholder has signed /affixed the thumb
impression after fully understanding the contents thereof.
X
Name of the Declarant : _______________________________ Signature:___________________________Relation with the Policyholder _____________________
Address of the Declarant : ____________________________________________________________________________ Contact No.: __________________________
I hereby certify that the contents of the form have been clearly explained to me and I have fully understood them. I further certify that the answers recorded in
the form are as per the information provided by me.

X
Signature/Thumb impression

Declaration Of Good Health (DGH)/V2/October 2023

IndiaFirst Life Insurance Company Ltd., Tel: +91 22 6165 8700 Fax: +91 22 6857 0600 Toll Free: 1800-209-8700
12th and 13th Floor, North [C] Wing, Tower 4, Nesco IT Park, Nesco Center,
Western Express Highway, Goregaon (East), Mumbai – 400063,
CIN: U66010MH2008PLC183679. E-mail: customer.first@indiafirstlife.com Website: www.indiafirstlife.com