Individual Insurance Form

(If yes please complete separate form for each person)

Medical History to Be Completed by The Proposer(Please Answer the Following Questions In Yes or No)

Are you in good health and free from physical and mental disease or infirmity?

Have you ever suffered from:

a) Any neruous, mental or psychiatric disease, slipped disc or other spinaldisorder, fainting episode, blackout, fit or paralysis of any kind?
b) High blood pressure, heart diseases including ischemic heart diseasepiles, varicose veins, other circulatory disorders or rheumatic fever?
c) Hernia, any rheumatic or joint disease, urinary disease or diabetes?
d) Any respiratory or allergic disease, or any disorder of the stomach,bowel or gall bladder?
e) Any other complaint requiring specialist's consultation or surgical orhospital treatment or investigations?
f) Any complaint or tendency that any necessitate such consultationor treatment in the future?
Are there any additional facts affecting the proposed insurance which shouldbe disclosed to insurers?
Have you any intention of engaging in winter sports or pastimes renderingyou liable to personal injury?