001 Trade Plaza, 414 Veer Savarkar Marg, Prabhadevi- Mumbai 400 025

Registration No 133
Minor Life Questionnaire (to be filled in by Proposer)

Name of life assured:

Application Number: Date of Birth (DD/MM/YY)of LA:
Please give full and accurate answers to each question.
Which Class Life assured is studying in?
Name of School:
DETAILS ABOUT THE CHILD’S HEALTH
Does the child have any physical problem /handicap or serious illness? Yes .. No ..

If yes, please give details:

Is any medication taken regularly by child, e.g., daily: Yes .. No ..

If yes, please give details:

Does the child suffers/ ever suffered from any of the following?

Yes No Age Yes No Age

Epilepsy / Convulsions Ear infection:
Heart / Lung problems? Measles/ Mumps:
Diabetes Convulsions:
Eczema Chickenpox:
Eating disorders Scarlet Fever:
Whooping cough: Bronchitis / Asthma
Glandular fever: Hearing Problem

If any of the above is ticked as “yes’, please provide details for the same

Any other relevant information or illnesses – Please state which and at what age:

DETAILS OF VACCINATIONS:

YES NO YES NO
Triple/Duo (Diphtheria,
Smallpox
Whooping Cough, Tetanus)
Polio Yellow Fever
MMR (Measles, Mumps,
Hepatitis
Rubella)
BCG/Tuberculosis Test Other vaccinations (Please
Tetanus last given specify)

I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance on my child’s life.

______________________ Date ________________(DD/MM/YYYY

Signature of Proposer
**Please tick √ wherever applicable. Place___________________