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