{"id":1980,"title":"REQUEST FOR ENDORSEMENT OF PRE-EXISTING DISEASE","purpose":"service","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/policy-wordings-product-brochure/ped_declaration_form.pdf","sha256":"7cd464b8910138512defbe5774abb2bcf383a6892d723795c11a48dc3c23b174","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder (proposer) to request an endorsement related to pre-existing diseases or surgeries after the policy has been issued.","notes":[],"title":"REQUEST FOR ENDORSEMENT OF PRE-EXISTING DISEASE","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Policy and Proposer Details","fields":[{"help":"Enter your insurance policy number.","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter your full name as proposer.","type":"text","label":"Name of Proposer:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration of Ailment(s) / Surgery to be Endorsed","fields":[{"help":"Enter your full name here.","type":"text","label":"I, Mr./Mrs./Ms. ____________________________________, hereby request the insurer to pass an endorsement related to the following ailment(s):","options":[],"required":null,"pdf_field":""},{"help":"Confirm your intention to disclose additional medical information with policy number and date of issuance.","type":"text","label":"I, [Proposer’s Name], hereby declare that I intend to disclosing additional medical information pertaining to pre-exiting medical condition (self/spouse/dependent) post issuance of policy (policy number), date of issuance DD/MM/YY.","options":[],"required":null,"pdf_field":""},{"help":"Fill details for each ailment or surgery: Name of Insured, Name of Ailment / Surgery to be Endorsed, Names and Dosage of Medicines Prescribed, Date of Diagnosis / Surgery (DD/MMM/YYYY).","type":"table","label":"Details of Ailment(s) / Surgery to be Endorsed","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Sign here to confirm the declaration.","type":"signature","label":"Signature of Proposer:","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing (DD/MM/YYYY).","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter the place where the form is signed.","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["Misrepresentation, non-disclosure, or concealment of material facts may result in policy cancellation or claim denial.","The proposer has read and understood the implications of this declaration and accepts insurer's right to take action if discrepancies are found.","Submission of this form does not imply approval; endorsement will be processed as per underwriting guidelines and policy terms."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/1980-request-for-endorsement-of-pre-existing-disease"}