Proposal Form No. šøÑzठ󡳢 >}. THYROID DISORDER

Proposal Form No. šøÑzठ󡳢 >}.
THYROID DISORDER QUESTIONNAIRE =àÒü¹ìÚìl¡¹ ¤¸à[‹¹ šøťऺã
The person to be insured should complete this statement:
ë™ ¤¸[v¡û¡¹ [¤³à A¡¹à Òì¤ t¡àìA¡ &Òü [¤¤õ[t¡[i¡ δšèo¢ A¡¹ìt¡ Òì¤:
Name: ______________________________________________________________
নাম
Date of Birth:
\@µ t¡à[¹J
1. Please state the exact diagnosis of your condition __________________________________________________________________________
">åNøÒ A¡ì¹ "àš>๠ì¹àìK¹ Î[k¡A¡ ì¹àK [>o¢Ú l¡üìÀJ A¡¹ç¡>
2. When was the condition diagnosed? What were the symptoms at time of diagnosis?
ì¹àK [>o¢Ú A¡ì¤ A¡¹à ÒìÚ[áº? ì¹àK [>o¢Ú A¡¹à¹ Î³Ú ì¹àK ºÛ¡oP¡[º [A¡ [áº?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
3. Have you undergone investigation for the condition?
&Òü ì¹àìK¹ \>¸ "àš>๠[A¡ ìA¡à> š¹ãÛ¡à-[>¹ãÛ¡à A¡¹à ÒìÚìá?
Yes
No
Ò¸òà
>à
(If yes, please give details and reports if available)
(™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o &¤} =àA¡ìº [¹ìšài¡¢ šøƒà> A¡¹ç¡>)
______________________________________________________________________________________________________________________
4. What treatment have you taken?
"àš>๠[A¡ [W¡[A¡;Îà A¡¹à ÒìÚìá?
______________________________________________________________________________________________________________________
5. When was the treatment ceased? (Was it advised by the doctor to stop the treatment?)
[W¡[A¡;Îà A¡ì¤ ¤Þê¡ A¡¹à ÒìÚìá? ([W¡[A¡;Îà ¤Þê¡ A¡¹à¹ š¹à³Å¢ [A¡ [W¡[A¡;ÎA¡ [ƒìÚ[áìº>?)
______________________________________________________________________________________________________________________
6. Are you currently taking medication?
"àš[> [A¡ ¤t¡¢³àì> *Èå‹ NøÒo A¡¹ìá>?
Yes
No
Ò¸òà
>à
(If yes, please provide the name and dosage of all medication)
(™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ "àš>๠Τ *Èå‹P¡[º¹ >à³ &¤} ³àyà l¡üìÀJ A¡¹ç¡>)
______________________________________________________________________________________________________________________
7. Do you have any condition of, or have been investigated or treated for any of the following?
"àš>๠[A¡ [>³¥[º[Jt¡P¡[º¹ ìA¡à>[i¡¹ ì¹àK "àìá "=¤à &P¡[º¹ ìA¡à> ì¹àìK¹ \>¸ š¹ãÛ¡à A¡¹à "=¤à [W¡[A¡;Îà A¡¹à ÒìÚìá?



Problem with your eyes and/or vision
Blood Pressure
ìW¡àJ &¤}/"=¤à ƒõ[Ê¡ Î}yû¡à”z γθà
¹v¡û¡W¡àš
Cardiac Vascular System
Òꡃ-Î}¤Ò> t¡”|
(If yes, please give full details in the space provide below)
Yes
No
Ò¸òà
>à
Yes
No
Ò¸òà
>à
Yes
No
Ò¸òà
>à
(™[ƒ Ò¸òà ÒÚ t¡àÒìº [>ì³¥ šøƒv¡ Ñ‚àì> δšèo¢ [¤¤¹o šøƒà> A¡¹ç¡>)
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
8. Please give the following details of your condition if diagnosed as Hyperthyroidism:
"àš>๠™[ƒ ÒàÒüšà¹=àÚ¹ìÚ[l¡\³ ì¹àK [>o¢Ú A¡¹à ÒìÚ =àìA¡ t¡àÒìº ">åNøÒ A¡ì¹ [>³¥[º[Jt¡ [¤¤¹o šøƒà> A¡¹ç¡>:
Are you being treated with radioactive iodine?
"àš>๠[A¡ ët¡\[ÑI¡Ú "àìÚà[l¡> ‡à¹à [W¡[A¡;Îà A¡¹à ÒìZá?
______________________________________________________________________________________________________________________
 Is there significant weight gain after the treatment?
[W¡[A¡;Î๠šì¹ [A¡ ºÛ¡oãÚ š[¹³àìo *\> ¤õ[‡ý¡ ëšìÚìá?
______________________________________________________________________________________________________________________
9. Does your daily activity restricted in anyway due to the condition?
&Òü ì¹àìK¹ \>¸ "àš>๠íƒ[>A¡ A¡à\A¡³¢ [A¡ ìA¡à> ®¡àì¤ Îã³à¤‡ý¡ ÒìÚìá?
Yes
No
Ò¸òà
>à
(If yes, please give details)
(™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
______________________________________________________________________________________________________________________
10. Please provide any additional information on your condition, which you feel, will be helpful in processing your application.
">åNøÒ A¡ì¹ "àš>๠ì¹àK Î}yû¡à”z "à>åÈ[UA¡ ì™ Î¤ t¡=¸ "àš>๠"à줃> šø[yû¡ÚàA¡¹ìo¹ ëÛ¡ìy ÎàÒà™¸ A¡¹ìt¡ šàì¹ ¤ìº "àš>๠³ì> ÒÚ
ëÎP¡[º šøƒà> A¡¹ç¡>
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information that may influence
the assessment or acceptance of this proposal.
I agree that this form will constitute part of my proposal (dated.............................) for life insurance and that failure to disclose any material fact known
to me may invalidate the contract between me and the Company.
"à[³ ìQàÈoà¡ A¡¹[á ë™ "à[³ ë™ l¡üv¡¹P¡[º [ƒìÚ[á ëÎP¡[º "à[³ ™t¡ƒè¹ \à[>, Ît¡¸ &¤} "à[³ &³> ìA¡à> P¡¹ç¡â«šèo¢ t¡=¸ ìKàš> A¡[¹[> ™à &Òü
šøÑzà줹 ³èº¸àÚ> "=¤à KõÒãt¡ Ò*ÚàìA¡ šø®¡à[¤t¡ A¡¹ìt¡ šàì¹ú
"à[³ δ¶[t¡ šøƒà> A¡¹[á ë™ &Òü ó¡³¢ìA¡ "à³à¹ \ã¤> [¤³à¹ šøÑzà줹 (t¡à[¹J.............................) "}Å ¹ê¡ìš Ko¸ A¡¹à Òì¤ &¤} "à³à¹
\à>à ìA¡à> P¡¹ç¡â«šèo¢ t¡=¸ šøA¡àÅ A¡¹ìt¡ "à[³ ¤¸=¢ Òìº ëÎi¡à "à³à¹ &¤} ëA¡à´šà[>¹ ³ì‹¸ Ò*Úà Wå¡[v¡û¡ìA¡ ¹ƒ A¡¹ìt¡ šàì¹ú
____________________________
____________________________
________________________________
___________________
Signature of the person to be insured
Date
_____________________________ ____________________________
Signature of witness
Name & Address of Witness
____________________________
____________________________
________________________________
___________________
ë™ ¤¸[v¡û¡¹ [¤³à A¡¹à Òì¤ t¡à¹ ѬàÛ¡¹
t¡à[¹J
_____________________________ ____________________________
Îàۡ㹠ѬàÛ¡¹
ÎàÛ¡ã¹ >à³ &¤} [k¡A¡à>à
A Joint Venture between Dabur Invest Corp. & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
l¡à¤¹ Òü>쮡С A¡š¢ &¤} "[®¡®¡à Òü@i¡à¹>¸àÅ>ຠëÒà[Á¡}Î [º[³ìi¡ìl¡¹ &A¡[i¡ ì™ï= l¡ü샸àK
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡
ëÒl "[ó¡Î: "[®¡®¡à i¡à*Úà¹, ëÎC¡¹ ì¹àl¡, [l¡&º&ó¡ Kºó¡ ìA¡àì΢¹ [¤š¹ãìt¡, [l¡&º&ó¡ ëó¡\ V, ëÎC¡¹ 43, P¡¹Kòà*-122003ú Ò[¹Úà>à Òü[“¡Úàú
[>¤[Þê¡t¡ A¡à™¢àºÚ 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢, [>l¡ü [ƒ[À-110001ú Òü[“¡Úà
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www.avivaindia.com Email/ Òü쳺 :[email protected]