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  • Age Declaration

    Enviado por

    Harish Chand
    25 visualizações2 páginas
    This document is a declaration of age form for an insurance policy. The applicant declares that they were born in a certain place on a certain date and that they are a certain age. As they have no other documentation to prove their age, they are making this declaration and allowing the insurance company to use it to determine their age for policy purposes. The declaration was made before a local official who certified that the applicant understood what they were declaring. A medical examiner also met the applicant and estimated their age based on appearance.

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    This document is a declaration of age form for an insurance policy. The applicant declares that they were born in a certain place on a certain date and that they are a certain age. As they have no other documentation to prove their age, they are making this declaration and allowing the insurance company to use it to determine their age for policy purposes. The declaration was made before a local official who certified that the applicant understood what they were declaring. A medical examiner also met the applicant and estimated their age based on appearance.

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    25 visualizações2 páginas

    Age Declaration

    Enviado por

    Harish Chand
    This document is a declaration of age form for an insurance policy. The applicant declares that they were born in a certain place on a certain date and that they are a certain age. As they have no other documentation to prove their age, they are making this declaration and allowing the insurance company to use it to determine their age for policy purposes. The declaration was made before a local official who certified that the applicant understood what they were declaring. A medical examiner also met the applicant and estimated their age based on appearance.

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 2

    Proposal No.

    /Policy No _____________________________________________________

    DECLARATION OF AGE

    I_________________________________ ________________son/daughter/wife
    of_______________________________byoccupation ___________________________
    residing at_______________________________________________________________
    do hereby affirm and declare that to the best of my knowledge and belief, I was born
    at_______________________on______________________________________and that
    (place) (State dateof birth if known)

    I am of ____________ year of age and that I have no other reliable documentary evidence
    of age to produce in proof of my age. I make this decleration conscientiously believing it to
    be true and knowing that on the faith hereof the Life Insurance Corporation of India will
    admit my age in their records.

    Signature of Proposer/Life Assured


    DECLARED BEFORE ME at______________________________________ and certified
    that the declaration has been read over to and understood by the deciarant.
    this ____________________ day of _________________ 2000

    (Seal)
    Secretary of the Panchayat / Member of
    The Panchayat/Block Development
    Officer/Tehsildar

    To be completed by an Appointed Medical Examinerof the Corporation.

    I here by certify that Shri_____________________________________________________


    Was identified before me byshri _______________________________________________
    And from his appearance he looks to be approximately________________ ______years old

    Signature of Proposer/Life Assured Signature of Medical Examiner

    Form No. 5096


    LPP 500x100 6-91

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