‘MAX LIFE INSURANCE CO. LTD. Regd, Office Max House, ] Dr Jha Marg, Okla, New Delhi -110 020 Heed office: 1" & 12" Floor, DLF Square Jacaranda, Marg, DLF City Phase 122 002, Haryana HEA TTARATION FORM _ (Please write in BLOCK LETTERS, Correction/Overwiting must bear fll signature) INSURANCE Request Type [1] Ratnstatement of pltey [1] Adation of Rider; Neme of the Riders [F]__ Dthers/statement of good health [E]_ tneroase in Sum Assured: Sum Assured (eg. new number case) NOTE: For Reinstatement of policy, Statomont of good healih - Complate Section A Forinerease in Sum Assured; Addiion ofider_~ Complete Section A+B POLICY HOLDER TFEWNSURED Tie TEs Ne Others epoaly Ths Mis Ohare (apes Fiat Taaie Last Te hore any change in he Yor Ne Yer We Correspondence adéress? Yes, please mention new aderess (along with address ‘roof sof attested) Name Contact deta: Tal No Taine Mobile Mobile Exar Reason for lapse “Ray sinultaneous request or reinstatement gven (1 yes, Specity the palcy numbers) H ‘Gurrert Occupation Got Pease specly Name ofthe ‘Company, Job ile, Nature of cuties} SECTION Thformation of fe nsured/polsy holder (Polley holder column should also be answered f payorriderla | Polleyholder Tie neured present) T._ Heightand Welght Tolght Fhe Information of or Mir__cms Moms weight Ka Ka Yes [No Yes [ No 7 Have you or Ga you consume TobaccaINicaine products (in Whe Bat years [SUASTOMEE Cigrates/aiesiCigarsiFlavored Pan masala et, yes, Please state the Quanily per dy T-Have you been off wore achoolroaine aclviios due Tofiness Ov Mur Tora Continuous pared af more Tan 410-cays in last tyear? IF Ves, Give details below 7 Inthe last 5 years have you sufered from any Tess oF Consulted any medial practioner Tar any condion tlner than minor impaitmanls such as commen cold? I Yes, Please give details below. 5, Has any proposallelastatomont for Me & heal Insurance over boon refused, Modif, postponed or ofored with extra premium by any oer company. Give datals below (reason, month, Year and Name of he co) ‘5 Have you ever Been Concted or are you under nvestgaton Tar any cfm punishable By 3 or Mors years oF irsprisonment? 7. isthe Life InauredIProposeriNomines/Payor a Poltically Exposed Person”? [MAX LIFE INSURANCEMeath declaration former 2.010 2012 3A Max India and @ MS Joint VentureSECTION Medicalinformation of ifeinsured/palicy holder(Policy helder column should also be answered if payor rider Is present) €. Family History. Has any of your fay members (parents and bing) ever diagnosed before he age of 60 wih (Diabetes, Hypertension, Cancer, Hear altac, Kidnay fale, Mutple Scleross or any herectary sorder? Il"Yes ive detail. ayes ane | Famty detais | Polley holder Lite insured FamWy Member | Age atdlagnosis | ~ Condition atciagosis Conon f 1 L L L ‘5 Have you over boon investigate ‘Woated or diagnosed with any of the following conditions Policy holder | Life insured Yes [No | Yes [Wo 1 Ghest Pain, crake, hear atack, murmur Hypertension or gh Blood pressure or any ofrer Rear condlion 7 Daneles Ti__Astrma, bronchs, Tuberculosis perustent cough, shortness of breath or any ofher_reapratary condiions TW Hormonal disorders such as tyroie disorders, Anaemia, eukon\a or afer blood aisordor ‘V_Liverigall tladder/stomach dsorders such as cirhosis,hepails, jaundice, ucer colts, gallstones, naigeston ‘wi Cancer, tumor or growth (Malignant or Benign) vi_Kidhey or bladder disorder. stones prostate disorder or gynecological Gsorder Tit_Epllepey, neurological disorder, mulipe serous, romors, paralysis, depression or payenatre Gao Tx. Disorder of eye, ea, nos0, lroal or back muscle, Joris, bone. neck deform. amputation. aris, out x Inthe last 5 years, have you been advised to have or nthe next 30 days wil you have_ an Xray ICT Scan WRU uilzasound /ECG rBlood test or any other investigatory or dagnastc tests or any type of surge Have you ever been treated tesiea postive for HIVIAIDS or hepais B/C or sewaly_tansmiled deste: xii Are you suffering from any other iliness or undergoing any nvestigaionfreatment other than the conditions ‘mentioned above? Tl_For female Aopicant only- Are you Pregnant? Ves, haw mary mont iv Are you afaching any Medical reports along with tis form ? "7 Do you paricipae or intend io participate n any hazardous aciviles such as Parachutng rang Giaing/Scuba DivingMounta neering/Car Racingtvng other than passenger}? Give deals below Tai Tn the next 12 months do you inion to travel or reside abroad other than on holday oflese than our weeks? Tr 35 Please provide details including counties, cies, pupase and duration of slay, Give deals below Detail: Dlaratlon: We futher agree and decar tht he eatrants and deciaratns mada nerain inte rectal long wih Secton A and shal be th basis fhe reinaatomentoftne pao pay ar adr cantata be nna eves ntwne ra adhe Carey ara Me hve ade cone and ace Secure ah as | fk ard a ri of yotermanc ah dr sab abt abe run drgag heel tek heer ets) el cos Cnt ‘evalfosvance datas wring to he pelcyeldt The Poy may be rantaod ot ee may bolesued of rewcodradocedcoveroge Units any shale allocated at the ‘eitaatemant dat o clearance date whichever sat We urdartaxs to rly the Corvany frit i wing cf any change noi of fh statements made nts Healt fodaatn for subsoauantto he signing of ths Real declaration form and rr to acceptance of hk ane rowvalof tho poleyiesuance othe rier by be Company ‘Signature Of Policy holder (ln'case of minor, Parentilegal guardian to Sign on behalf ofthe minor) Place: Incase of Policyholder is iliterate/Thumb impression/Understands language other than English: | hereby declare that | have explained the contents of this form to the PoleyholderLife Insured in Language and thatthe PoleyholderLie Insured has axed the thumb impression(s) above aller fully Understanding the contents, Signature ofthe Declarant Adress: Date = Pltcaly Exposed Persons (PEP) oe niduals who oof heve deen ertusted wih prominent pute fnclons for example Hes! Miitrs of Cota Stats government Semsorpeticans, Serer goverment ual raltayofcars, Geri enecuve of sat goed oxporatons, portent potal pry ole &nmosale fal mettbr of ove persone (Spouse, Chldron, Parent, Slings, aw MAX LIFE INSURANCE'Healh gecaratin foxmiVor2.0ty 2012 A Max India and @® MS Joint Venture s-