Business/Occupation
(describe fully nature of duties)
(b)
Age next birthday
(c)
Height/Weight
ft.
k.g.
(d)
Approximate annual income
3.
Does Insured Person(s) duties involve:
(a)
(b)
If so give full details:
4.
Has Insured person(s) suffered from:
(a)
Physical defect/infirmity.
(b)
Complaint relating to eye sight ,hearing,chronic disease, arthritis,diabetes,fit gout,paralysis.
if so give full details.
5.
(a)
Is Insured person(s) at present or had he been Insured for Personal Accident Risks?
(b)
Has Insured Person(s) ever sustained disabledment from accident?
(c)
Has Insured Person(s) made any claim under Personal Accident Policy?
(d)
Has any company declined proposal, or cancelled Insurance or required special terms or refused renewal thereof?
If so, give details.
6.
State any other information material to this Risk.
7.
(a)
Capital Sum Insured required Rs.
NRs.
(b)
Benefits required:
8.
Period of Insurance:
From:
To:
WE HEREBY DECLARE AND WARRANT that above statements are true and complete. We shall be basis of Contract between us and the Company and we agree to accept Policy subject to conditions prescribed by the Company.
