Revival of Lapsed Policy (Form 680). Page 1 of 3 (Established by the Life Insurance Corporation Act, 1956) PERSONAL STATEMENT REGARDING HEALTH (Revival of Lapsed Policies on both Medical & Non-Medical basis) Agent’s Name : Divl. Office: Branch Office: Policy No 1. Full name of the Life Assured Address1 Full Address2 Address Address3 Email Address Phone/Mobile No Occupation Name of Employer Length of Service with him years 2. Since the date of your Proposal for the above mentioned Policy: Answer 'Yes' or 'No' If 'Yes" give details of ailment such as nature of illness, date of onset, duration of illness etc. (a) Have you ever suffered from any illness/disease requiring treatment for a week or more? (b) Did you ever have any operation, accident or injury? (c) Did you ever undergo ECG, X-Ray, Screening, Blood, Urine or Stool examination? 3. Has a proposal or an application for revival of a policy on your life made to this or any other Office of the Corporation or any Insurer ever been: (i) Withdrawn or dropped? (ii) Accepted with an extra premium or lien? (iii) Deferred or declined? (iv) Accepted on terms otherwise than those proposed? If so, give details: (b)Is any proposal or an application for revival of a. lapsed policy on your life under consideration of this or any other Office of the Corporation? If answer is 'Yes' give the (i) Proposal No. following details: (ii) Policy No. F. NO. 680 ( Rev. 680 ) Date of Receipt _____________ Inward No. _____________ Revival of Lapsed Policy (Form 680). Page 2 of 3 4. Are you at present in sound health? N.B. - For Revivals under Non-medical scheme (Question Nos. 5 & 6) 5. (i) State your height (without shoes) cm. (ii) Your weight (with thin clothes.) kgs 6. State below, details of all your policies issued and/or revived under any of the Non-Medical Schemes of the Corporation: Name of the Divl. Office /Unit Br. Office Servicing the Policy Policy Number Sum Assured Status of the Policy For Females only: (i) Have you been menstruating regularly? (ii) Have you had any miscarriage/s? (iii) Are you pregnant now? (iv) State the date of last menstruation: 7. Since the date of your proposal under the above mentioned policy: (v) State the date of last delivery: DECLARATION I …………… do hereby declare that the foregoing statements and answers are true and complete in every particular, and agree and declare that these statements and this declaration along with my Proposal for Insurance under the lapsed policy shall be the basis of the contract of revival of the lapsed policy between me and Life Insurance Corporation of India, and that if any untrue averment be contained therein, the said contract shall be absolutely null and void and all moneys which shall have been paid in respect thereof, shall stand forfeited to the Corporation. And I further declare that if between the date of this declaration and the date of revival of the policy (i) any change in any occupation or any adverse circumstances connected with my financial position or the general health of myself or that of any member of my family occurs or (ii) a Proposal for assurance or any application for revival of a policy on my life made to any Office of the Corporation is pending or has been withdrawn or dropped, deferred or declined or accepted at an increased premium or subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to reconsider the terms of Revival of the Policy. Any omission on my part to do so shall render the Revival absolutely null and void and all moneys which shall have been paid in respect thereof, shall stand forfeited to the Corporation. Dated at on the day of (month) 20 Signature of Witness Name : Occupation : & Address : Signature or Thumb impression of the Life Assured Revival of Lapsed Policy (Form 680). Page 3 of 3 "If in this form, the answers to the questions and/or signature of the Life Assured are given in vernacular, then the Life Assured should declare in his own handwriting above his own signature that all questions were explained to him and that his replies were given after fully and properly understanding the same." (1)This declaration should be made by the person filling in the form Name & Address Of the declarant (1) I hereby declare that I have fully explained the above questions to the Life Assured and I have truthfully recorded the answers given by the Life Assured. Signature In case the Life Assured is Illiterate: (2) The thumb impression of the Life Assured should be attested by a person of standing whose identity can easily be established, but unconnected with, the Corporation and this declaration should be made by him: Name & Address Of the declarant (2) I hereby declare that I have explained the contents of this form to the Life Assured in (language) and that I have read out to the Life Assured, the answers to the questions dictated by the Life Assured and that the Life Assured has affixed his thumb impression to this form after fully understanding' the contents thereof. Signature
