Protective Islami Life Insurance Ltd.

Health Insurance Application Form for Student

(To be filled by Coders Trust Student)

Name of Proposed Insured:  
Father's Name:  
Mother's Name:  
Date of Birth :  
Mailing Address:  
Mobile No.  
Height (cm):  
  Weight (kg):*
National ID:  
PP Size Photograph of the Insured   Photo size Maximum 150kb
Signature of Proposed Insured / Applicant   Signature size Maximum 30kb
1. Are you now in good Health & entirely free from any physical impairment or deformities? Yes No
2. Have you ever had or been advised to have a blood test for AIDS or an AIDS related conditions or have you ever been Refused as a blood donor? Yes No
3) Has any proposal for insurance/application for revival of a policy on your life been declined/postponed/withdrawn or accepted with extra premium or any restrictive clause or on terms other than proposal ? Yes No
4) For Females only (for married woman) : Since the date of your applying for Life insurance with PILIL : a. Are you pregnant or not ? Yes No
5) Have you any history of Cancer, leukemia Hodgkin’s disease, lymphoma, brain or spinal tumours including benign brain or spinal growths ? Yes No
6) Do you have history of Heart disease, including heart attack, angina, cardiomyopathy (a condition of the heart muscle) or heart valve disorder, Bypass surgery (last 1 yr) Yes No
7) Do you have history of Stroke, brain hemorrhage, paralysis, transient ischemic attack (mini stroke)or any permanent brain injury ? Yes No
8) Do you have history of Mental illness that has required psychiatric or hospital assessment or treatment, schizophrenia, bi-polar disorder, manic depression ? Yes No
9) Disease or disorders of the liver or pancreas, including cirrhosis or pancreatitis? Yes No
DECLARATION:The forgoing statements and answers are full, complete and true & I have not concealed any information's .I agree that they shall be the basis of insurance for me and the Protective Islami Life Insurance Limited shall not be liable for any claim of hospitalization the cause of which was known prior to approval of my request for assurance and withheld or concealed in the above statements. I hereby authorize any physician , nurse , hospital official or employee to disclose to the Protective Islami Life Insurance Limited any information it requests about me with reference to any treatments, examinations , advice or hospitalization.


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