{"id":2314,"title":"PERSONAL STATEMENT REGARDING HEALTH (Revival of Lapsed Policies on both Medical & Non-Medical basis)","purpose":"proposal","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/dgh-680","sha256":"d679a9192277fbf7b566ef163449b6ee1f5751a82731aba998d845e4c81ef878","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the life assured to provide personal and health information required for the revival of a lapsed insurance policy, either on a medical or non-medical basis.","notes":["In case the proposer is illiterate, the thumb impression should be attested by a person of standing unconnected with the Corporation.","The declarant must explain the form contents to the proposer in a language understood by the proposer.","Use the exact formats requested, e.g., date in yyyy-mm-dd for last delivery date.","Answer all questions truthfully and provide full details where requested."],"title":"PERSONAL STATEMENT REGARDING HEALTH (Revival of Lapsed Policies on both Medical & Non-Medical basis)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Personal Details and Contact Information","fields":[{"help":"","type":"text","label":"Agent’s Name :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Agent’s Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Division Office:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch office:","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Select appropriate title and enter full name","type":"text","label":"Full name of the Life Assured Mr./Mrs./Ms./Mx.","options":["Mr.","Mrs.","Ms.","Mx."],"required":true,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender:","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Enter your full postal address","type":"text","label":"Full Address Address1 Address2 Address3","options":[],"required":true,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""},{"help":"Enter your phone or mobile number","type":"phone","label":"Phone / Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter your current occupation","type":"text","label":"Present Occupation","options":[],"required":false,"pdf_field":""},{"help":"Enter your employer's name","type":"text","label":"Name of Employer","options":[],"required":false,"pdf_field":""},{"help":"Enter number of years with current employer","type":"number","label":"Length of Service with employer ……years","options":[],"required":false,"pdf_field":""}],"filled_by":"life assured"},{"title":"Personal Medical History","fields":[{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Have you remained absent from place of work on grounds of health during the last 5 years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous System?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Are you suffering from or have ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Did you ever have any bodily defect or deformity?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Did you ever have any accident or injury?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No; if Yes, provide full details","type":"yes-no","label":"Have you ever required or at present availing/undergoing medical advice, treatment or tests in connection with hepatitis B or AIDS related condition.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select your usual health status","type":"choice","label":"What has been your usual state of health?","options":["Good","Not Good"],"required":true,"pdf_field":""},{"help":"If Yes, provide Policy/Proposal No., Branch, Year","type":"yes-no","label":"Is your life now being proposed for another assurance or an application for revival of a policy on your life or any other proposal under consideration in any office of the Corporation or to any other Insurer?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, provide Policy/Proposal No., Branch, Year","type":"yes-no","label":"Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation or to any other Insurer ever been: Withdrawn or Dropped?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, provide Policy/Proposal No., Branch, Year","type":"yes-no","label":"Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation or to any other Insurer ever been: Accepted with an extra premium or lien?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, provide Policy/Proposal No., Branch, Year","type":"yes-no","label":"Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation or to any other Insurer ever been: Deferred or declined?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If Yes, provide Policy/Proposal No., Branch, Year","type":"yes-no","label":"Has a proposal (or an application for revival of a policy) on your life made to any office of the Corporation or to any other Insurer ever been: Accepted on terms otherwise than those proposed?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"life assured"},{"title":"Details of Insurance Policies under Proposal/Revival","fields":[{"help":"Enter the name of the divisional office or unit","type":"text","label":"Name of the Divisional Office/Unit","options":[],"required":false,"pdf_field":""},{"help":"Enter the branch office name","type":"text","label":"Branch Office","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Enter plan and term details","type":"text","label":"Plan & Term","options":[],"required":false,"pdf_field":""},{"help":"Enter sum assured amount","type":"amount","label":"Sum Assured","options":[],"required":false,"pdf_field":""},{"help":"Enter policy status and date of last premium paid","type":"text","label":"Status of Policy / Last Premium Paid on","options":[],"required":false,"pdf_field":""}],"filled_by":"life assured"},{"title":"Female Proponent Specific Questions","fields":[{"help":"Answer if currently pregnant","type":"yes-no","label":"Are you pregnant now?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter date of last delivery in yyyy-mm-dd format","type":"date","label":"Date of last Delivery (yyyy-mm-dd):","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you had any abortion or miscarriage or caesarian section? if so give details","options":[],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you ever consulted a gynecologist or undergone any investigation, treatment for any gynaec ailment? (If yes, give details)","options":[],"required":false,"pdf_field":""}],"filled_by":"life assured (female only)"},{"title":"Declaration by the Life Assured","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature or Thumb Impression of the Life Assured.","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Provide address and contact number of witness","type":"text","label":"Address and Contact Number","options":[],"required":false,"pdf_field":""},{"help":"If proposer is illiterate, declarant must provide name and address","type":"text","label":"Name and Address of the Declarant","options":[],"required":false,"pdf_field":""}],"filled_by":"life assured"}],"deadlines":[],"applies_to":"Revival of Lapsed Policy","attachments":[],"declarations":["The statements and answers given are true and complete and form the basis of the insurance contract.","If any information is untrue, the contract will be dealt with as per Section 45 of the Insurance Act, 1938 as amended.","The life assured authorizes doctors, hospitals, employers, and others to share relevant information with the Corporation for underwriting and claim purposes.","The life assured agrees to inform the Corporation in writing of any changes in occupation, health, financial position, or other proposals before revival.","Failure to inform the Corporation of such changes will result in the contract being dealt with as per Section 45 of the Insurance Act, 1938 as amended."],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"+91-22-68276827","label":"Customer Care Phone Number","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of LIC\nMission/Vis","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"8976862090","label":"Customer Care Phone Number","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"e Insurance Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"'Yogakshema' , Jeevan Bima Marg, P.O. Box No19953, Mumbai – 400 021.","label":"Corporate Office Address","level":null,"hours":null,"applies_to":"all","source_url":"https://licindia.in/web/guest/grievances","quote":"any grievances, email at\nco_complaints[at]licindia[dot]com\nCorporate Office\n: Life Insurance Corporation of India \r\n\t\t\t\t'Yogakshema' , Jeevan Bima Marg, P.O. Box No19953, \r\n\t\t\t\tMumbai – 400 021. IRDAI Reg No- 512\nFor any query regarding this website, please contact the Web Information Manager\nSmt. Himali As","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"co_healthsc@licindia.com","label":"Senior Citizens Health Grievance Email","level":null,"hours":null,"applies_to":"health","source_url":"https://licindia.in/documents/20121/124155/Sample_Policy_Document_LIC-s-Arogya-Rakshak.pdf/ed974eaa-4330-7732-6a85-43cfd7980a67?t=1669266625981","quote":"District Court Judge is member of each of the Claims Dispute Redressal Committees. For Senior Citizens:\nEmail address: co_healthsc@licindia.com Health Toll free Number: 18004259876\nOf IRDAI:\nIn case the customer is not satisfied with the response or do not receiv","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-22-68276827","label":"LIC Call Center","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of LIC\nMission/Vis","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"8976862090","label":"LIC Call Center","level":null,"hours":"24*7","applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"e Insurance Corporation \r\n   of India.\nNavigation\nSkip to Content\nMenu Display\nVoice Search\nSearch\nSkip to main content\n8976862090\n+91-22-68276827\nBranch Locator\nLanguage Selector\nenglish\nहिन्दी [beta]\nमराठी\nA+\nA\nA-\nA\nA\nAbout Us\nHistory\nObjectives Of","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"sms","value":"SMS LICHELP <pol.no.> to 9222492224","label":"Grievance Redressal SMS","level":null,"hours":null,"applies_to":"all","source_url":"https://licindia.in/phone-help-line","quote":"Branch / Division / Zonal / Corporate Level.\n(For details click on the `Grievances' tab on the homepage).\nSMS LICHELP :\nSMS LICHELP <pol.no.> to 9222492224.\nDetails of Health Insurance TPA along with Toll Free Numbers\n(Content: English | Format: PDF | View/Download |Size: 44","fetched_at":"2026-10-20"}],"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/lic/2314-personal-statement-regarding-health-revival-of-lapsed-policies-on-both-medical-a"}