Health Declaration Letter

SBI Life - Swadhan (Group) UIN: 111N014V01
GOOD HEALTH DECLARATION FORM

Guidelines:

✓ All Sections/Fields in this form should be completed. Leaving the questions unanswered will not be accepted and may lead to rejection of the proposal.

✓ Insurance is a contract of utmost good faith, trusting the life assured to disclose all the fact. In case of any doubt as to whether a fact is material or not, the fact should be disclosed.

✓ The revival of the policy will be effective from the date of acceptance of the revival request and shall further be subject to the receipt of full premium amount due on revival, by the company.

Name of the Life Assured (Member)

SBI LIFE CUSTOMER ID:

I, hereby apply for Revival (Readmission) of Cover:

I declare that I am presently in sound mental and physical health.

I also declare that I do not have any physical defect/deformity, and perform my routine activities independently.

I have never suffered from nor am I currently not suffering from diabetes, hypertension (high blood-pressure), epilepsy, or tuberculosis or genetic disorder.

I have not been tested positive for Hepatitis B, Hepatitis C, or HIV and have not been treated or hospitalized in connection with alcohol, narcotic drugs or tobacco consumption. During the last 3 years, I have not been hospitalized for any ailment or disease. I have not taken any treatment nor am I currently receiving any treatment nor have I been advised to undergo medical tests or follow any prescribed line of treatment, for critical illness in the past or in the present.

@ A Critical Illness is defined as any one of the following:

[1] have suffered or be suffering from cancer, [2] be advised or be taking treatment for any heart disease, [3] have undergone any major surgery requiring full anesthesia during the last 12 months, [4] have undergone major organ transplant, [5] have been advised medically to undergo chest/heart surgery or surgery requiring full anesthesia within the following six months from the date of declaration, [6] have kidney and/or liver failure, [7] have suffered or be suffering from stroke, paralysis, or any mental illness, [8] have suffered or is suffering from any chronic, irreversible disease of the lungs or brain or liver, [9] have suffered or be suffering from AIDS or venereal diseases.

For females only, At present, I am not pregnant.

I hereby understand and agree that no insurance cover will commence until this revival request is accepted and requisite premium due for revival has been received by SBI Life and SBI Life conveys its written acceptance of this request for revival of cover. I further understand and agree that such revival of insurance cover provided to me shall be governed by the Master Policy Contract issued in favor of the Group Master Policyholder.

Notwithstanding the provision of any law, usage, custom or convention for the time being in force prohibiting any doctor, hospital and/or employer from divulging any knowledge or information about me concerning my health, employment on the grounds of secrecy, I, my heirs, executors, administrators or any other person or persons having interest of any kind whatsoever in the insurance cover provided to me, hereby agree that such authority, having such knowledge or information, shall at any time be at liberty to divulge any such knowledge or information to the Company.

I hereby declare and agree that the foregoing declaration has been given after fully understanding the same and is true and complete to the best of my knowledge and that I have not withheld any information that may influence the revival of my cover under the Group Insurance Scheme of SBI Life Insurance Co. Ltd. I hereby agree that this form including the declaration herein shall form the basis of my re-admission into the Group Insurance Scheme and if any untrue statement be contained therein, I, my heirs, executors, administrators, and assignees shall not be entitled to receive any benefits under the said Group Insurance Scheme. I also agree that the Company shall not be liable for any claim on account of illness, injury, or death, the cause of which was known prior to approval of my request for revival, withheld or concealed in the above statements.

Name and Designation of the Bank official

Counter signature of Bank official

ANY OTHER MATERIAL FACTS PERTAINING TO HEALTH OR OTHERWISE

DECLARATION WHEN THE MEMBERSHIP FORM IS FILLED BY A PERSON OTHER THAN THE GROUP MEMBER/GROUP MEMBER SIGNS IN A VERNACULAR LANGUAGE / GROUP MEMBER IS ILLITERATE (THUMB IMPRESSION CASES)

I hereby declare that I have read out and explained the contents of membership form and all other documents incidental to availing the Group Insurance Scheme from SBI Life Insurance Company Ltd to the Group Member and that he/she said that he/she had understood the same and the he/she agrees to abide by all the terms and conditions of the same.

I hereby declare that I have fully explained to the Group Member that the answers to the questions form the basis for the Group Insurance Cover and that if any untrue statement is contained herein, no benefits will be payable by the SBI Life.

I hereby declare that I have explained the contents of this form to the Group Member in Language, that I have truly and correctly recorded the answers given by the Group Member and that the Member has affixed his/her signature/thumb impression on the membership form in my presence, after fully understanding the contents thereof.

Date:

Section 41 of the Insurance Act, 1938: “No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer”

Section 45 of Insurance Act, 1938: “No Policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall, after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material do disclose; Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.”