{"id":2315,"title":"प्रकृती संबंधी वैयक्तिक कथन / PERSONAL STATEMENT REGARDING HEALTH","purpose":"proposal","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/form-no-720","sha256":"b9f305f66c29cfbae431c152a317635cdf2e29798ca9fb16ddb0c51a28300b5f","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for the proposer to provide a personal health statement when applying for revival of a lapsed policy or issue of a new policy under the C.D.A. plan with deferment period of 10 years or more.","notes":["Write all answers in block letters where specified.","Answer all health questions with Yes or No.","If any answer is Yes, provide full details including dates, duration, and doctors consulted.","If answers or signature are in a language other than Hindi or English, a declaration in own handwriting is required above the signature.","If proposer is illiterate, thumb impression must be attested by a reputable person unconnected with LIC.","In case of dispute in interpretation, the English version of the form shall prevail."],"title":"प्रकृती संबंधी वैयक्तिक कथन / PERSONAL STATEMENT REGARDING HEALTH","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer and Policy Details","fields":[{"help":"","type":"text","label":"प्रस्ताव / पॉलिसी क्र. / Proposal / Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"एजंटचे नाव / Agent's Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"एजंटचा संकेत क्रमांक / Agency Code No.","options":[],"required":null,"pdf_field":""},{"help":"Write in block letters","type":"text","label":"1. प्रस्तावकाचे पूर्ण नाव / Full Name of the Proposer (IN BLOCK LETTERS)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"पूर्ण पत्ता / Full Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"व्यवसाय / Occupation","options":[],"required":null,"pdf_field":""},{"help":"Write in block letters","type":"text","label":"2. वीमित व्यक्तिचे पूर्ण नांव / Full Name of the Assured / Life to be Assured (IN BLOCK LETTERS)","options":[],"required":true,"pdf_field":""},{"help":"If applicable","type":"text","label":"प्रस्ताव सं. / Proposal No.","options":[],"required":null,"pdf_field":""},{"help":"If applicable","type":"text","label":"पॉलिसी सं. / Policy No.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Medical History","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"4) Since the date of your above mentioned proposal / policy proposal date: (a) Has he / she suffered from any illness / disease requiring treatment for a week or more?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"(b) Did he / she have any operation, accident or injury?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"(c) Did he / she undergo E.C.G., X-ray, Screening, Blood, Urine or Stool examination?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if any answer above is Yes","type":"text","label":"If 'Yes' give details of ailment date & duration, doctors consulted.","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"5) (a) Has a proposal or an application for revival of policy on his / her life made to this or any other Office of the Corporation or any insurer ever been: Withdrawn or dropped? Deferred or declined? Accepted with an extra premium or lien? Accepted on terms otherwise than those proposed?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"(b) Is any proposal or an application for revival of a lapsed policy on his / her life under consideration of this or any other office of the Corporation?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"6) Is he / she now in sound health?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide class/standard if student","type":"text","label":"7) Is he / she a student? if so, in which standard?","options":[],"required":null,"pdf_field":""}],"filled_by":"life assured / proposer"},{"title":"Declaration","fields":[{"help":"Witness signature required","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"For a policy on another life under C.D.A. plan with deferment Period 10 years or more on the date of proposal or revival of Policy.","attachments":[],"declarations":["The statements and answers given are true and form the basis of the insurance contract or revival.","If any untrue statement is found, the contract will be void and all monies paid will be forfeited.","If any change in occupation, health, financial status or proposal status occurs between declaration and revival date, proposer must inform LIC in writing immediately.","Failure to inform LIC of such changes will render the insurance invalid and monies paid forfeited.","If answers or signature are in vernacular, proposer must declare in own handwriting that questions were explained and answers given after understanding.","If proposer is illiterate, thumb impression must be attested by a person of standing unconnected with LIC who must declare that questions were explained and answers truthfully recorded."],"dropped_labels":9},"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/2315-personal-statement-regarding-health"}