{"id":2318,"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-700-1-","sha256":"cf891a7b0ee2bb29941c4bd565123663304d0f115498c6587f4d1666871dcd38","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by a proposer and the life to be assured to provide personal and health-related information for the revival of a lapsed life insurance policy or for a new policy proposal, excluding certain deferred plans.","notes":["Use block letters for names.","This form is not to be used for policies vested in or assigned to the life assured or for Child Deferred Annuity plans with deferment period of 10 years or more.","If answers or signatures are in vernacular, a declaration in own handwriting is required.","In case of dispute, 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 Details","fields":[{"help":"Write in block letters","type":"text","label":"प्रस्तावकाचे संपूर्ण नांव * / प्रस्तावक का पूरा नाम * / Name in full of the Proposer.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"संपूर्ण पत्ता* / पूरा पता* Full Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"दूरध्वनी क्र./ Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"इ-मेल / E-mail :","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"एजन्टचे नांव आणि कोड क्रमांक / अभिकर्ता का नाम और संकेत संख्या / Agent's Name and Code No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Life to be Assured Details","fields":[{"help":"Write in block letters","type":"text","label":"वीमित व्यक्ति / वीमा इच्छूक ह्यांचे संपूर्ण नांव / बीमार्थी / बीमेदार का पूरा नाम / Name in full of the Life to be Assured / Life Assured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"मालकाचे नांव / नियोक्ता का नाम / Name of Employer","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"व्यवसाय / Occupation","options":[],"required":false,"pdf_field":""},{"help":"Specify duration","type":"text","label":"नोकरीचा कालावधि / सेवा अवधि / Length of Service","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Application Type","fields":[{"help":"Provide Proposal No. or Policy No. as applicable","type":"text","label":"उत्तर ‘होय’ असल्यास प्रस्ताव क्रमांक किंवा पॉलिसी क्रमांक द्या. / यदि उत्तर 'हाँ' है तो कृपया प्रस्ताव संख्या या पॉलिसी संख्या दें। / If the answer is \"Yes\" please give the Proposal or the Policy Number","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questions (to be answered by Life to be Assured)","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Have you suffered from any illness / disease requiring treatment for a week or more?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered Yes above","type":"text","label":"If 'Yes' give details of ailment, date & duration, doctor consulted.","options":[],"required":false,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Did you have any operation, accident or injury?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Did you undergo ECG, X-Ray, Screening, Blood, Urine or Stool examination?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"Previous Proposal or Revival Applications","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Has a proposal or an application for revival of a policy on your life made to this or any other Office of the Corporation or any insurer ever been withdrawn or dropped?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Is any proposal or an application for revival or a lapsed policy on your life under consideration of this or any other office of the Corporation?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"Physical Measurements (for revival under Non-medical scheme)","fields":[{"help":"In centimeters","type":"number","label":"आपली उंची (वहाणा / पादत्राणां शिवाय) / State your height (without shoes)","options":[],"required":true,"pdf_field":""},{"help":"In kilograms","type":"number","label":"आपले वजन (पातळ कपड्यांसह) / Your weight (with thin clothes)","options":[],"required":true,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"Details of Policies under Non-medical Scheme","fields":[{"help":"Provide office name","type":"text","label":"Name of Divl. Office / Unit Branch Office Servicing the Policy","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Assured","options":[],"required":false,"pdf_field":""},{"help":"Current status","type":"text","label":"Status of the Policy","options":[],"required":false,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"Current Health and Student Status","fields":[{"help":"","type":"yes-no","label":"Are you at present in sound state of health?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Are you a student? If so, give particulars such as name of the institution and course.","options":[],"required":false,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"For Females Only","fields":[{"help":"","type":"yes-no","label":"Have you had any miscarriages?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you pregnant now?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"State the date of the last menstruation","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"State the date of last delivery","options":[],"required":false,"pdf_field":""}],"filled_by":"life to be assured (female)"},{"title":"Declaration by Life to be Assured","fields":[{"help":"","type":"signature","label":"Signature or thumb impression of the Life to be Assured/Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Witness name, occupation & address required","type":"signature","label":"Signature of witness","options":[],"required":true,"pdf_field":""}],"filled_by":"life to be assured"},{"title":"Declaration by Proposer","fields":[{"help":"","type":"signature","label":"Signature or thumb impression of the proposer","options":[],"required":true,"pdf_field":""},{"help":"Witness name, occupation & address required","type":"signature","label":"Signature of witness","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Revival of lapsed policies except for Child Deferred Annuity (C.D.A.) plans with deferment period of 10 years or more; also for new policy proposals","attachments":[],"declarations":["The statements and answers given by the Life to be Assured under headings 4 to 10 are true and complete and no information is withheld.","The statements and answers given by the Proposer under headings 1 to 3 are true and complete and form the basis of the contract with LIC.","If any change occurs in occupation, financial or health status, or if any proposal/application is withdrawn, deferred, declined or accepted on different terms between declaration and revival date, the proposer must inform LIC in writing immediately.","Failure to inform LIC of such changes will render the assurance invalid and all monies paid will be forfeited.","If answers or signatures are given in a local language, the person must declare in their own handwriting that all questions were explained and understood before answering.","If the proposer/life assured is illiterate, a declarant must certify that the form was explained and answers recorded truthfully.","Thumb impression of the proposer/life assured must be attested by a person of standing unconnected with LIC."],"dropped_labels":18},"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/2318-personal-statement-regarding-health"}