Escolar Documentos
Profissional Documentos
Cultura Documentos
ID No.
Nature of Work (Please tick whichever is applicable) (Wvwscawj wgwhWf Luwgnwr iawgiawb ELgu cnk
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Engaged either occasionally or generally in manual work which involves the use of tools or machinery
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Mode of premium payment: Cash Cheque Bank order Salary deduction Internet banking
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Family History u WmUlAuwm egWliaWa
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Have you previously made any life proposal with Allied? Yes No
Family history Age if living State of health Age at death Cause of death
Father
Mother
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Brothers
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Sisters
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a. In addition to the visit mentioned above have you consulted any other medical practitioner (please give name) during Yes No
If Yes give full particulars: 2-2
b. Have you ever attended hospital for treatment, operation or investigation or had any x-ray? Yes No
1. Bronchitis, asthma or any other complaint of the lungs or respiratory system. Yes No
2-6
Yes No
b. Are you a beta Thalassaemia carrier?
3. Any form of nervous breakdown or depression or have you consulted a psychiatrist? Yes No
10. Hepatitis B, any sexually transmitted disease, including genital sores or discharges? Yes No
3-6
11. Stroke High or Low blood pressure? Yes No
16. Any disease or disorder of the eyes, ears, nose or throat? Yes No
d. Are you taking any medicine or drug or receiving any treatment? Yes No
4-6
e. Has any Insurance company ever requested any additional premium or postponed or declined a Yes No
proposal for life assurance on your life?
Do you have any intention or expectation?
Yes No
f. Have you ever had or been advised to have a blood test for AIDS or an AIDS related condition? Yes No
Yes No
Yes No
2. Have you had any miscarriage?
Yes No
3. Are you pregnant now?
Yes No
4. Have you suffered from any disease of breast, ovaries or uterus?
5. State date of last menstruation
6. State date of last delivery
5-6
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Name: Relationship:
ID No. Address:
Name: Relationship:
ID No. Address:
DecIaration: I hereby declare that the above answers and statements are true, and that I have not withheld any information whatsoever regarding this proposal. I agree
that this Declaration and answers given above, together with those made by me to the medical examiner acting on behalf of the company shall form the basis of the
contract with the company. I hereby further declare that I agree that in the event the declaration shall contain any misstatement, misrepresentation, suppression and/
or fraud, the issuance of the policy shall not be nor deemed to be a waiver of such misstatement, misrepresentation, suppression and/or fraud. I hereby authorize any
hospital, surgeon, medical practitioner or clinic or other person who attended to me for any reason to disclose to the Insurance Company any and all information with
shall be considered as effective and valid as the original. I acknowledge that the liability of the Insurance Company does not commence until this proposal is accepted
by and premium paid to the Insurance Company.
To be completed and signed by the proposer (If other than life to be assured) (wmwn cnUn ctWrwf Wvwgcnwn cscnwrwax
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Name: Relationship:
Contact No: Mobile No: Address:
Email: Sign: Date:
THIS INSURANCE WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY
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