Questionnaire to be completed by Loan Applicants for Life Insurance

The Applicant

Amount

Benefits Requested
Total Permanent Disablement
No Yes
Partial Permanent Disablement
No Yes
Passive War
No Yes

Beneficiary (ies)

Questions to be answered by Loan Applicant

IMPORTANT NOTICE
The answers given below will form the basis of the loan insurance contract and any false declarations in this form may invalidate the insurance cover - PLEASE ANSWER ALL QUESTIONS TRUTHFULLY

Personal History
1- Have you ever suffered from any form of heart disease (including abnormal blood pressure), elevated cholesterol, stroke, cancer, diabetes, kidney disease, mental illness, hepatitis, HIV infection or AIDS ?
No Yes


2- Have you ever suffered from any other chronic or long term medical condition not mentioned above ?
No Yes


3- Have you within the last 2 years taken any form of medication for more than 14 consecutive days to treat an illness or disease?
No Yes


4- Have you been absent from work or taken leave on health grounds for more than 10 days during the last 12 months ?
No Yes


5- During the past 5 years, have you consulted any medical practitioner for any condition other than minor impairments (such as colds or flu) or been hospitalized or had a surgical operation?
No Yes


6- Has any application for life, disability or health insurance been declined, postponed or accepted with special terms or restrictions?
No Yes


7- Do you have any reason to believe that you are not in good health?
No Yes


8- Do you have any physical/bodily deformity?
No Yes


Details of illness I injury if any of the above questions have been answered 'Yes'

Family History (please note this relates only to natural blood relatives)

Relationship	Age If Living	Present state of health	Age at Death	Cause of Death	Add
Father Mother Brother Sister

Build & Habits

Has your mass changed by more than 5kg during the past year ?
No Yes
Height (cm): Weight (kg):

Have you been smoking during the last 12 months?
No Yes
If Yes, state daily use of tobacco below:
Quantity per day of : Cigarettes Cigars Pipe, Sheesha or any other form of tobacco

Do you consume alcohol?
No Yes
If Yes, state type and quantity per day or week below:

Type	Quantity

Did you drink more regularly in the past or ever have an alcohol related problem (whether treated or not) ?
No Yes
If Yes please provide details

Declaration

1.1 declare that to the best of my knowledge and belief the above statements are true.
2.1 am aware that the insurer accepts the above declaration in good faith and that if this declaration is proved to be wrong or if any material information regarding my health has been withheld, the insurer may not be liable to pay any of the insured outstanding loan amounts.
3.1 am also aware that, for permanent total disability cover, pre-existing conditions of ill health are excluded and agree that in case of any previous serious medical history due to accident or sickness or for any congenital disabilities or psychiatric illness, the disability insurance cover is excluded.
4.1 have no objection to obtaining any medical records from any hospitals regarding any medical history.

Note to Bank
In case the answers above contain declarations with regard to adverse health, further medical requirements as agreed should be obtained and submitted to the insurer before cover is confirmed. The customer should be made aware that any fraudulent declaration shall result in cancellation of all insurance cover.
Signature and Seal of the Bank Authorized Official