Declaration of Good Health Form PDF
Declaration of Good Health Form PDF
Declaration of Good Health Form PDF
Received Date:
Date of Birth: D D M M Y Y Y Y
Address:
Are you a US Citizen or US tax resident Yes No) If Yes, Please provide TIN:
10 Since the date of signing of proposal, has there been any change in your occupation, financial position Yes/ No
or annual income, vocation/hobbies?
Additional Information
15 Any other information material for the evaluation of risk, kindly provide details -
If any of the above questions have been answered as “Yes”, kindly provide details (Please mention question number while providing details).
Q. No. Details
Since the date of my last proposal to Bharti AXA Life Insurance Company Limited, there has been no change in my health.
• I declare that the above answers are correct to the best of my knowledge and belief. I declare that the answers/declarations given above shall be the basis of
the insurance contract between Bharti AXA Life Insurance Company Limited and myself. If the answers/declarations contained herein are untrue, the said
insurance contract shall be treated as null and void
• I/we agree that the Company may provide/transfer/retain any information available with the Company related to me/us, obtained in connection with
processing of my proposal or the policy and servicing thereof to any reinsurers, insurance association, medical registrar, statutory authorities/bodies or services
providers engaged by the Company for policy servicing related activities without any further reference to me/us
Place: Date: D D M M Y Y Y Y
Vernacular Declaration
DECLARATION IN CASE THIS DGH FORM IS FILLED BY A PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE:
Declaration by Policyholder:
I hereby declare that the contents in this form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as per
the information provided by me.
Thumb impression/Signature of the Policyholder
Declarant’s Address:
Date of Birth: D D M M Y Y Y Y
Date: D D M M Y Y Y Y
Declarant’s Signature: Place:
*"The person giving this declaration can be any person other than Introducing Advisor or MOA or MOM"
Bharti AXA Life Insurance Company Ltd. Regd. Office: Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East,
Mumbai -400051, Maharashtra Regn. No.: 130. CIN no: U66010MH2005PLC157108.
Service address: Bharti AXA Life Insurance Company Ltd., Spectrum Tower, 3rd Floor, Malad Link Road, Malad (West), Mumbai - 400064.
1800-102-4444 SMS SERVICE to 56677 We will be in touch within 24 hours to address your query www.bharti-axalife.com Comp-Oct-2010-1118AA