Bangoli Weight Loss Questionnaire B10

Proposal Form No:
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Weight Loss Questionnaire
*\> Òùàìι 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 of the life to be Insured: _______________________________________: DOB
™à¹ \ã¤> [¤³à A¡¹à Òì¤ t¡à¹ >à³:
\@µ t¡à[¹J
1. Have you lost any weight during the last 12 months? (If yes, please provide details)
Yes
Ò¸òà
"àš>๠[A¡ Kt¡ 12 ³àìÎ *\> ÒùàÎ ëšìÚìá? (™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
No
>à
____
________________________________________________________________________________________
2. What was your approximate weight (in Kilograms) before the “weight loss”? _______________________________
''*\> ÒùàÎ'' &¹ šè줢 "àš>๠"à>å³à[>A¡ *\> A¡t¡ [Ạ([A¡ìºàNøàì³)?
3. How much weight (in Kilograms) has been lost since? _________________________________________________
ëÎÒü Î³Ú ë=ìA¡ A¡t¡i¡à *\> ([A¡ìºàNøàì³) ÒùàÎ ëšìÚìá?
4. Was the weight loss:
&Òü *\> ÒùàÎ [áº:
a. Rapid (eg mostly in last 3 months)? (If yes, please give details) ______________________________
Yes
No
b. Gradual (over last 12months)? (If yes, please give details)
Yes
No
Yes
No
6. Have you been on an exercise program or weight loss program during this period?(If yes, please provide details) Yes
No
‰ç¡t¡ (왳> ë¤[Ź®¡àKÒü ëÅÈ 3 ³àìÎ)? (™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
______________________________
‹ãì¹ ‹ãì¹ (ìÅÈ 12 ³àÎ ‹ì¹)? (™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
5. Have you been on any particular weight loss “diet“ during this period? (If yes, please provide details)
"àš[> [A¡ &Òü γÚA¡àìº *\> ÒùàÎ A¡¹à¹ \>¸ ìA¡à> [¤ìÅÈ ''l¡àìÚi¡'' ">åιo A¡¹[áìº>? (™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹
____
______________________________________________________
[¤¤¹o šøƒà> A¡¹ç¡>)
Ò¸òà
Ò¸òà
Ò¸òà
&Òü γÚA¡àìº "àš[> [A¡ ìA¡à> ¤¸àÚà³ A¡à™¢yû¡ì³ "=¤à *\> Òùàìι \>¸ ìA¡à> A¡à™¢yû¡ì³ "}ÅNøÒo A¡¹[áìº>?
Ò¸òà
___________________________________________________________ (™[ƒ Ò¸òà ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [¤¤¹o šøƒà> A¡¹ç¡>)
>à
>à
>à
>à
7. Is there any particular known cause of the weight loss noticed?
š[¹º[Û¡t¡ *\> Òùàìι \>¸ ìA¡à> [¤ìÅÈ `¡àt¡ A¡à¹o "àìá [A¡?
____
________________________________________________________________________________________
____
________________________________________________________________________________________
8. Please provide any other information that may be relevant? Attach latest medical reports.
">åNøÒ A¡ì¹ ">¸ ìA¡à> t¡=¸ ™à šøàÎ[UA¡ Òìt¡ šàì¹ šøƒà> A¡¹ç¡>ú Îà´ß[t¡A¡t¡³ [W¡[A¡;Îà [¹ìšài¡¢ γèÒ Î}™åv¡û¡ A¡¹ç¡>ú
____
________________________________________________________________________________________
____
________________________________________________________________________________________
I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any
"à[³ ìQàÈoà A¡¹[á ë™ "à[³ ™t¡ƒè¹ \à[> &Jàì> šøƒv¡ "à³à¹ ÎA¡º l¡üv¡¹ Ît¡¸ &¤} "à[³ P¡¹ç¡â«šèo¢ &³> ìA¡à> t¡=¸ ìKàš> A¡[¹[> ™à &Òü šøÑzà줹
³èº¸àÚ> "=¤à KõÒãt¡ Ò*ÚàìA¡ šø®¡à[¤t¡ A¡¹ìt¡ šàì¹ú
.........) for life insurance and that failure
I agree that this form will constitutepart of my proposal (dated....................
to disclose any material fact known to me may invalidate the contract between the Company and me.
"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 &¤} ìA¡à´šà[>¹ ³ì‹¸ Ò*Úà Wå¡[v¡û¡ìA¡ ¹ƒ A¡¹ìt¡ šàì¹ú
________________________________
________________________________ _____________________________
Signature of the person to be insured
ë™ ¤¸[v¡û¡¹ [¤³à A¡¹à Òì¤ t¡à¹ ѬàÛ¡¹
Signature of Witness
Îàۡ㹠ѬàÛ¡¹
________________________________
Name & Address of Witness
ÎàÛ¡ã¹ >à³ &¤} [k¡A¡à>à
Date __/__/__
t¡à[¹J
A Joint Venture between Dabur Invest Corp & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
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¡
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Phase V, Sector 43, Gurgaon-122003. Haryana, India. Registered
Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
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
Uw /Med Q/Ver 1.0/1st April 2011