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Declaration of Good Health Form for Health/Life Insurance Policy (Sample)

Some insurance companies take a signed declaration form for good health from its policyholders well in advance before the insurance policy is issued to that person or just after it.

Declaration of Good Health Form for Health/Life Insurance Policy (Sample)It happens especially in cases of health insurance companies issuing health insurance policies to its policyholders. This is done as a precautionary measure so that a person who is already sick/ill from any disease do not take advantage of the insurance company knowingly.

The declaration form will be given by the insurance company to the policy holder for going through it and signing it. Or you can write a declaration letter with all necessary details.



FORMAT

Date: ..................

To
(Name of the Insurance Company)
(Branch Name and address)

Sub.: Declaration of good health for my health insurance policy
Ref: Insurance policy application no. ............. dated ..............

Dear Sir,

I have applied to your company for issuing a life/health insurance policy in my name as per the following details.

My name: .........................
Address: ........................
Date of birth: ...............
Gender: ....................
Nationality: .................
Occupation: ....................
Contact No.: ......................
Email id: ..............................

I understand it is a prerequisite that I should declare the factual situation of my current state of health.

Therefore, kindly note the followings:

I declare that I am of good and sound health at present to the best of my knowledge. I do not have any physical disability or deformity or any defects. I was not hospitalised during the last one year period nor do I expect to be hospitalised in near future for any disease.

I further declare that since the date of proposal of the policy I have not taken up any hazardous occupation neither I have suffered from any illness/ disease requiring treatment for a week or more nor I have had any operation, accident or injury nor I have undergone ECG, X-ray, screening, blood, urine or stool examination nor I have lost/gained in weight of 5 kgs or more during the last one year period.

I further declare that there has never been any instances of any proposal for insurance / application for revival of a policy on my life that has been declined or postponed or withdrawn or accepted with extra premium or any restrictive clause or on terms other than proposal.

I declare and affirm that the information provided herein above is true and correct to the best of my knowledge and belief. I agree that the above information will constitute part of my contract for life/health assurance with your company.

I understand and agree that the statements herein this Declaration of Good Health constitute warranties. I understand that any mis-statement or suppression of material information be contain therein, shall make the entire contract of insurance between me and your company, absolutely null and void.

I, therefore, request you to kindly issue/approve/revive my health insurance policy for which I shall be grateful to you.

Sincerely,

   signature

(Name of the person/policy holder)

Comments

  1. Thank you

    ReplyDelete
  2. Bhausaheb Patil10/03/2018

    Good format. Was helpful during preparation.

    ReplyDelete

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