Application for Reinstatement - CSC 20 · 2020-04-24 · APPLICATION AND HEALTH CERTIFICATE in...
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Transcript of Application for Reinstatement - CSC 20 · 2020-04-24 · APPLICATION AND HEALTH CERTIFICATE in...
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APPLICATION AND HEALTH CERTIFICATE in connection with Reinstatement Removal/Reduction in Rating Policy Number : Change in Plan Amount
Insured’s Name :
Policy Owner’s Name :
Declarations: (Please tick each box below)
the undersigned, declare that since the date of signing the Application for the said Policy, I and all insureds named above and covered in this policy:
1. Average monthly income over past 12 months …………………………………
2.
3.
4. I/we do not intend to travel during the next twelve months. If not, here are the travel details.
5. a) passenger route. b) I/we do not undertake or have plans to undertake any hazardous sport or activity such as Diving, Mountain Climbing, etc.
6. I/We am/are in good health and do not intend to seek medical advice or undergo medical tests.
7. I/we have not met with any illness or accident, and have not consulted any medical facility, or done tests including those connected with HIV or AIDS.
8. No deaths have occurred in the family (Parents, Brothers, Sisters).
9. I am a female; I am not pregnant.
Dated on
Name and address of Witness
Signature of Witness
Current Correspondence Address:
E-mail Address : Phone Number:
Current Residential
Insured
Daily DutiesNature of BusinessEmployer’s NameHeight WeightRelationship to policy owner
No. Details
*Exceptions to the Declaration*
Insurance in force on the insureds under the Policy, including Personal Accident Coverage.
Company Name Policy Number Amount Effective Date
Rating Type of Coverage
this day of 201
Name of Applicant in own handwriting
Signature of Applicant
CSC-20
Name Destination Purpose Duration
Policy Owner
Address
Mobile No.I declare that each of the above answers are full, complete and true and agree that they shall be taken as the basis of the reinstatement, change or issue of the above insurance, and that such reinstatement, change or issue shall not be considered as affected by reason of settlement made in payment of or on account of the amount now due until this application shall be duly approved by the Company, and that the receipt, retention, deposit or cashing of any such payment or settlement by the Company or its agent shall not constitute a waiver or forfeiture, or otherwise affect this condition. I also understand that, notwithstanding any provisions to the contrary in said policy, the policy, but not any part thereof granting Disability or Accident Benefits, if basic face amount is increased or reinstated, shall become incontestable after it has been in force during the lifetime of the insured for two years from the date of this application, except for non-payment of premium, fraud and willful misrepresentation. I understand that an incomplete or incorrect statement may invalidate the policy.
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