Declaration

I/We further agree and declare that the statements and declarations made herein shall be the basis of the reinstatement of the lapsed policy and/or rider. I/We have made complete, true and accurate disclosure of all the facts and circumstances as may be relevant, and have not withheld any information that may be relevant to enable the company to make an informed decision about the acceptability of the risk. I fully understand that the revival of my policy and/or rider shall be subject to life to be insured undergoing medical test (whenever required), at policy holder's cost, realization of applicable charges for revival. Revival of a lapsed policy and/or rider shall be subject to the company underwriting the risk afresh and confirming the revival/issuance details in writing of the policyholder. The policy may be reinstated of the rider may be issued at revised/reduced coverage. I/we undertake to notify the company, forthwith in writing, of any change in any of the statements made in health declaration form and prior to acceptane of risk and revival of the policy and/or of the rider.

I Agree

[{"quesId":"travelledOrPlanTravel","quesText":"<p>Have you traveled abroad post 1st Jan 2020 OR do you have plan to travel overseas in upcoming 6 months ?</p>\n"},{"quesId":"covidWarrior","quesText":"<p>Are you a Health Care Worker, directly involved in serving COVID diagnosed people?</p>\n"},{"quesId":"sufferedFromAnySymptoms","quesText":"<p>In the last 1 year, did you or your family member(s) suffered from -flu like symptoms, fever, sore throat, runny nose, persistent cough, sore throat, shortness of breath, breathing difficulties, malaise, gastro-intestinal symptoms such as nausea, vomiting, diarrhea, advised to undergo test or awaiting test results for SARS-CoV-2/COVID-19*?</p>\n"},{"quesId":"contactOrSelfTestedPositive","quesText":"<p>In the last 1 year Have you had direct contact with someone who has been confirmed or is suspected to SARS-CoV-2/COVID-19* positive? Or have you Tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)?</p>\n"},{"quesId":"quarantineNotice","quesText":"<p>Are you serving a notice of quarantine in any form imposed by local health authorities or government or airport authority for possible exposure to novel coronavirus (SARS- CoV2/COVID-19)?</p>\n"}]

[{"quesText":"<p>Have you or your family member(s) traveled abroad since 01/01/2020?&nbsp;</p>\n","subQues":[{"subQuesId":"nameOfCountriesTravelled","subQuesText":"Please mention name of the country/countries travelled to ","subQuesType":"country"},{"subQuesId":"dateOfReturn","subQuesText":"Date of return","subQuesType":"date"}],"quesId":"familyOrSelfTravelledAbroad"},{"quesText":"<p>Do you intend to travel abroad within the next 6 months?</p>\n","subQues":[{"subQuesId":"nameOfCountries","subQuesText":"Please mention name of the country/ countries","subQuesType":"country"},{"subQuesId":"intendedDateOfTravel","subQuesText":"Intended date of travel","subQuesType":"date"},{"subQuesId":"durationOfStay","subQuesText":"Duration of stay (Enter in Days)","subQuesType":"text"}],"quesId":"intendingTravelAbroad"},{"quesText":"<p>In the last 3 months, are you currently or your family member(s) suffering from or have suffered from -flu like symptoms, fever, sore throat, runny nose, persistent cough, sore throat, shortness of breath, breathing difficulties, malaise, gastro-intestinal symptoms such as nausea, vomiting, diarrhea, advised to undergo test or awaiting test results for SARS-CoV-2/COVID-19*?</p>\n","subQues":[{"subQuesId":"selfOrfamilyMemberAnySymptoms","subQuesText":"Please select SELF Or FAMILY MEMBER","subQuesType":"custom-radio"},{"subQuesId":"exactDiagnosis","subQuesText":"Please specify exact diagnosis","subQuesType":"text"},{"subQuesId":"dateOfDiagnosis","subQuesText":"Date of diagnosis","subQuesType":"date"},{"subQuesId":"recovery","subQuesText":"Have you recovered?","subQuesType":"radio"},{"subQuesId":"dateOfRecovery","subQuesText":"Date of Recovery","subQuesType":"date"}],"quesId":"familyOrSelfAnySymptoms"},{"quesText":"<p>Have you had direct contact with someone who has been confirmed or is suspected to SARS-CoV-2/COVID-19* positive? Or Have you Tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)?&nbsp;</p>\n","subQues":[{"subQuesId":"positiveDiagonsisDate","subQuesText":"Please mention date of positive diagnosis for SARS-CoV-2/COVID19* (please mention NA if not applicable)","subQuesType":"text"},{"subQuesId":"nameOfTest","subQuesText":"Specify the name of test done (please mention NA if not applicable) ","subQuesType":"text"},{"subQuesId":"subsequentTestDetails","subQuesText":"Details of subsequent tests (please mention NA if not applicable)","subQuesType":"text"},{"subQuesId":"requireAdmissionToHospital","subQuesText":"Did you require admission to hospital?","subQuesType":"radio"},{"subQuesId":"stay","subQuesText":"Please mention did you require stay in","subQuesType":"custom-radio"},{"subQuesId":"otherStay","subQuesText":"Please mention other stay (If Any)","subQuesType":"text"},{"subQuesId":"ventilatorSupport","subQuesText":"Please mention did you require support of a ventilator","subQuesType":"radio"},{"subQuesId":"fullPhysicalRecovery","subQuesText":"Have you made a full physical function recovery, able to perform your normal occupational or daily duties, without any ongoing symptoms or restrictions (i.e. shortness of breath or fatigue)? ","subQuesType":"radio"},{"subQuesId":"recoveryDate","subQuesText":"Date of Recovery","subQuesType":"date"}],"quesId":"directContactToCovidPatient"},{"quesText":"<p>Are you serving a notice of quarantine in any form imposed by local health authorities or government or airport authority for possible exposure to novel coronavirus (SARS- CoV2/COVID-19)?&nbsp;</p>\n","subQues":[{"subQuesId":"location","subQuesText":"Please specify location","subQuesType":"text"},{"subQuesId":"quarantinePeriodFrom","subQuesText":"Quarantine period from date","subQuesType":"date"},{"subQuesId":"quarantinePeriodTo","subQuesText":"Quarantine period to date","subQuesType":"date"}],"quesId":"servingQuarantineNotice"}]

[{"quesText":"<p>Please specify your occupation</p>\n","subQues":[],"quesId":"occupation","quesType":"text"},{"quesText":"<p>Please specify medical Specialty (if applicable)</p>\n","subQues":[],"quesId":"medicalSpeciality","quesType":"text"},{"quesText":"<p>Please specify exact nature of duties (including procedural or non-procedural duties)&nbsp;</p>\n","subQues":[],"quesId":"natureOfDuties","quesType":"text"},{"quesText":"<p>Please specify name and address of the healthcare facility or facilities in which you work.&nbsp;</p>\n","subQues":[],"quesId":"healthcareFacilitiesNameAndAddress","quesType":"textarea"},{"quesText":"<p>Please specify name of the Health Authority under which you are registered.</p>\n","subQues":[],"quesId":"nameOfHealthAuthority","quesType":"text"},{"quesText":"<p>Does your healthcare facility have sufficient personal protective equipment (PPE) to provide to its workforce?&nbsp;</p>\n","subQues":[],"quesId":"sufficientPersonalProtective","quesType":"radio"},{"quesText":"<p>Have you been or do your work duties involve close contact with anyone who has been quarantined or who has been diagnosed with novel coronavirus (SARS-CoV-2/COVID-19)?&nbsp;</p>\n","subQues":[{"subQuesId":"natureOfWork","subQuesText":"Pease provide details including nature of work for patients with novel coronavirus (SARS-CoV-2/COVID-19) ","subQuesType":"text"}],"quesId":"closeContactWithCovidPatients","quesType":"radio"},{"quesText":"<p>Have you ever been on voluntary leave, or placed on compulsory leave of absence/sick leave, due to a possible exposure to novel coronavirus (SARS-CoV-2/COVID-19)?</p>\n","subQues":[{"subQuesId":"relevantPeriod","subQuesText":"Please provide relevant period/dates ","subQuesType":"text"},{"subQuesId":"relevantDetails","subQuesText":"Please provide relevant details (If any)","subQuesType":"textarea"}],"quesId":"voluntaryLeave","quesType":"radio"},{"quesText":"<p>Are you currently in good health?&nbsp;</p>\n","subQues":[{"subQuesId":"healthDetails","subQuesText":"Please share details","subQuesType":"text"}],"quesId":"currentlyGoodHealth","quesType":"radio"}]

Have you ever been diagnosed or treated for any health issues related to any of the following? 

• Heart, Kidney, Liver
• Diabetes, Hypertension
• Cancer, HIV/AIDS, Surgery
• Brain stroke, Paralysis
• Tuberculosis

Is the Life Insurer/Proposer/Nominee/Payor a Politically exposed person*?

Have you ever or Do you consume Tobacco/ Nicotine products (in last 3 years (sticks/gms)-Cigarettes/Bidis/Cigars/Flavored Pan Masala etc.?