Enter Unique application number
Details of the Life to be Insured
Do you smoke more than 10 cigarettes / consume 2 sachets of Guthka/tobacco per day
Do you consume more than 60 ml of Alcohol per day?
Health Declaration for Proposed Life Insured
  • 1.Apart from minor ailments such as cold and flu, have you ever received any treatment from, or consulted with any doctor or been hospitalized in the last five years?
  • 2.Have you ever suffered in the past or are you currently suffering from:
    (a) Diabetes mellitus, high blood sugar levels or sugar in urine
    (b) High blood pressure, chest pain, heart attack, heart murmur, shortness of breath or any other heart condition
    (c) Stroke, paralysis, transient ischemic attack, epilepsy, head injury, tremors, dizzy or fainting spells, blurred or double vision or any other nervous disorder
    (d) Recurrent indigestion, ulcer, jaundice, hepatitis, cirrhosis, kidney stone, kidney failure or any other disease of the stomach, bowels, liver, kidney, urinary bladder, prostate or reproductive system
    (e) Sexually transmitted disease or AIDS or positive HIV
    (f) Cancer, tumour, leukemia, enlarged lymph nodes or any abnormal growth or any hormonal disorders or disorders of the blood and lymphatic system, eyes, ear, nose, throat
    (g) Asthma, tuberculosis, chronic cough, chronic bronchitis, emphysema, pneumonia or any other disease of the respiratory system
    (h) Anxiety, depression or any other Mental disorder
    (i) Rheumatic arthritis, joint disease, bone disorders, muscular dystrophies, musculoskeletal deformities or any physical deformity or congenital birth defects
    (j) Thyroid or endocrine disease, digestive and bowel disorder
    (k) Any other condition, symptom, disease not stated above
  • 3.Have you ever been advised to undergo any surgery or treatment or laboratory investigations (such as but not limited to stress ECG, echocardiogram, angiography, MRI/CT scan etc.) by any doctor or specialist?
  • 4.Has any application or proposal for life, health, accident or critical illness including renewal and reinstatement ever been declined, deferred, withdrawn or accepted at special rates or terms by Aviva Life Insurance or any other insurance company?
  • 5.Do you currently have or in the past had any other medical condition, illnesses, diseases, disorders, disability, surgery or treatment or are intending to seek medical advice for a condition not mentioned above?
  • 6.Is your occupation associated with any specific hazard or do you take part in activities or have hobbies that could be dangerous in any way for example paragliding, bungee jumping, etc.?
  • 7.Have you ever received or do you now receive any disability or critical illness benefits from any insurance company?
  • 8.Have you been off work due to illness for a continuous period of 7 days and above during the last 5 years?
  • 9.Do you have two or more members of your family who have (father, mother, brother(s) or sisters(s)) suffered from or are suffering from cancer, heart disease, kidney failure, stroke, diabetes, or any hereditary disease?
  • 10.(For females only) Are you pregnant?
  • 11.(For females only) Are you suffering, being investigated or treated for any pregnancy related complication or any other gynecological disorder?
  • 12.Were you ever hospitalised for Covid infection or its complication or do you have any ongoing complications related to Covid Infection? [If the answer is 'yes', then kindly provide, details of such hospitalisation (discharge summary) or treatment details related to complication noted and investigated]
  • If Yes to any question, please provide details (and attach relevant questionnaire)
I hereby declare that the above statements are true and complete in every respect and that I have not withheld or omitted to give any information related to my personal particulars or my health.
I agree to inform the Company in writing of any change in my health and circumstances between the date of this Declaration and the issue of the Certificate of Insurance in respect of my Life Insurance Coverage.
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