Confirm to Proceed Payment

Health Statements

have you been admitted to hospital in the last 12 months?   

Reason of Admission in Hospital   

Do you have any medical conditions?   

What medical condition you have   

• I have not been admitted to a hospital in the past 12 months.
• I do not have any Pre-existing medical condition (what is pre-existing medical condition?)
• Are you now or were you ever a member of any military force?
  Are you now engaged or intend to engage in any private flying, hazardous sports, hazardous pastime activity or racing?
  Has any application or reinstatement of your life insurance / takaful, critical illness,health or accidental insurance / takaful on ever been declined, postponed, rated -up- or in any way modified by a takaful operator or any other insurance company?
  Please state whether this application is to replace or intend to replace any existing certificate with dft or other company?
  Is there any history of enemity or criminal record?
  Have you ever suffered or been investigated, diagnosed or treated for:
  Asthma, tuberculosis or any other respiratory, or lung disease?
  Palpitation,chest pain, difficulty in breathing, heart attack, high blood pressure,high blood cholesterol or any other disease of heart?
  Peptic ulcer gastritis, pain in abdomen or any other disease of stomach or intestine?
  Jaundice, hepatitis, any other liver, pancreas or gall bladder disease or been a hepatitis -b or hepatitis - c carrier?
  Protein, blood in urine, kidney stones or any disorder of urinary system?
  Epilepsy ,fever, fits, paralysis, stroke, mental disorder, or any disease of the brain or nervous system?
  Diabetes mellitus, sugar in urine, goiter or any disease of the thyroid or other metabolic disease?
  Cancer, tumor, cyst or any swelling?
  Sexually transmitted disease?
  Enlarged lymph nodes,rheumatic fever, severe skin disease, anemia or any other blood disorder?
  Arthritis, gout, disorder of the spine, back bones, joints, or muscles?
  Severe injury to any parts of the body or any other illness not mentioned above?
  Have you / your spouse ever recieived medical advice, been tested for hiv or treated for aids (acquired immune deficiency syndrome) or arc (aids related complex)?
  Have you anytime in the past 3 months, had continuous and unexplained symptoms of fatigus or tiredness, diarrhea weight loss, loss of appetite, enlarged lymph nodes or unusual skin lesions?
  Have you ever been refused as a blood donor or ever received any blood transfusions or blood products?
  Diagnostic test such as x-ray, electrocardiogram, urine / blood test, ultra sound, mammogram,or biopsy etc.
  Surgical operation, medical advice or hospital admission / treatment due to any reason mentioned or not mentiond above have you ever met with any accident within last 5 years, please give details.
  Have you ever met with any accidengt within last 5 year? if yes please give details.
  Are you now pregnant ? if "yes" , since how many months?
  Have you ever had disease of the breast, female organs menstrual disorders,abnormal result of pap smear test or any other complications at child birth?
  Have any of your family members had or been told to have any diseases, illness, impairments mentioned or not mentioned above? if yes, give details
  Do you smoke?
  Do you take narcotics, any habit forming drugs or alcohol?
  Have you ever used any of habit forming drugs or narcotics or been treated for alcoholism or drugs habits?
  Do you have any birth defect, physical deformity or disability?
  

Agreement.

I hereby confirm that all of the answers and statements made and marked above by myself are true, have been understood by me and that no material facts concerning my past and present state of health and habits have been withheld or omitted. Further I declare that to the best of my knowledge, the forgoing statements are true and complete and I understand that such disclosures will form part of the basis of the contract of life insurance and I am duly bound to make full, complete and absolute disclosure. I further affirm to understand that failure to disclose and withholding any material information in context of this policy may lead to cancellation of Policy, forfeit of premium and rejection of claim. I further confirm that the premium amount paid is not derived from money laundering or illegal activities.