SBIL - Health Questionnaire
SBIL - Health Questionnaire
_/__/____
OR NRI
PIO
Designation:
Nature of duties:
Marital Status:
Male
Female
Foreign National
Specify County in case NRI/PIO/ Foreign National or Currently Posted Outside India_______________________
Weight: ________Kgs.
1. Have you consulted any doctor for surgical operations or have been hospitalized for any disorder or been advised to undergo any medical
investigations/treatment for any medical condition other than for minor cough, cold or flu during the last 5 years?
2. Are you currently taking or in the past have taken any treatment or medications or special diet for any condition for a continuous period of
more than 14 days? (except for minor cough, cold, flu, appendix, typhoid )
3. Have you ever suffered from or have been advised that you have any of the following conditions (If yes, please tick the relevant and please
complete the details in table 1)
Yes
No
Yes
No
Yes
No
High cholesterol
Stroke/paralysis
4. Have you had or have been advised to undergo any of the following test or investigations. (If yes please provide details in the table 1)
Ultra sonography
CT Scan/MRI Biopsy
Coronary Angiography.
Yes
No
5. a)Do you consume more than 10 cigarettes / bidis per day? Or chew more than 5 pouches Tobacco per day?
Yes
No
b) Do you consume more than 2 pegs of alcohol per day in any form? If yes, please provide the type of alcohol and daily quantity
consumed.
Type : ________________________
Quantity consumed: _______________________
Yes
No
Yes
No
6. Has your proposal for life insurance, ever been declined, postponed, withdrawn or accepted at extra premium or reduced cover?
Yes
No
7.Does your work involve working in mines, rig, high sea, underground or on heights or exposure to harmful chemical or gases etc
Yes
No
8. Do you take part in or have you any prospect or intention of taking part in any other hazardous sports, hobbies or pursuits? (eg. In aviation
other than as a fare paying passenger, diving, mountaineering, racing etc )
Yes
No
Yes
No
Yes
No
c) Do you use or have you used any narcotics /any other drugs?
( ___________ months)
b. Have you suffered from any gynecological problems or illness related to breasts, uterus or ovary?
If answers to any of the questions (1) to (7) are Yes please give full particulars below with details such as medical history, diagnosis, date of
diagnosis, treatment taken, names of medications, tests done, results of tests as under Table 1
Details of treating
Doctor / Surgeon
(Name, Qualification,
Contact No.)
Date of first
diagnosis
Date of Last
consultation
Details of
current
symptoms
List of medication
being consumed
currently
Provide details of
any further
consultation /
surgery planned?
_____________________________________
Signature / thumb impression of the Member
Date:
______________________________________________
Signature /Thumb Impression of the Witness
Name and address of the Witness: __________________
__________________________________
Name
______________
Place
____________________
Date
Under the provisions of section 45 of the Insurance Act, 1938, the Company is entitled to repudiate a policy on the ground that a statement
made in the proposal or in any report of a medical officer or referee or friend of the insured or any other document leading to issue of the
policy was inaccurate or false, before the expiry of 2 years from the effective date of the policy, and thereafter that if such false or
inaccurate statement was on a material matter or suppressed facts were material to disclose and it was fraudulently made and the policy
holder knew that the statement was false or was material to disclose.