Guardian Life Insurance Limited

Head Office: Chamber Building (9th Floor),

122-124, Motijheel C/A, Dhaka-1000

Health Insurance Policyholders Application Form

(Please use block letters all through)
1. Name of Employer
2. Name of Policyholders
3. Designation

4. ID / PF No.

5. Current Address
6. DATE OF BIRTH
8. Marital Status:

Day

Month

Year

Married Unmarried Divorcee / others

10. Dependents to be included in the Plan

Name

Male

7. SEX

Date Of Birth

Female

9. No. of Children
Sex

Relationship

11. Coverage for: Self Spouse Family (Spouse & Children)

12. Plan Option: Plan-A Plan-B Plan- C Plan-D Plan-E
Health Questionnaire
No insurance cover will apply in respect of any condition, or linked condition, which exists, or has existed
before the acceptance of risk by Guardian Life Insurance Limited., unless it has been declared to and accepted
by Guardian Life Insurance Limited. It is therefore, in your interest to answer these questions fully and
provide information.
If the answer is Yes, write details in the space provided below:

Within the last five years, have you or any member of your family applying for insurance
(a) been incapacitated for a period of more than 10 days as a result of any illness, injury,
Yes
disability or impairment?
(c) consulted a specialist or attended a clinic as an out patient for the purpose of an
Yes
investigation , test, X-ray, or operation?
(e) consulted any doctor about any condition or impairment which still exits or has left any Yes
residual effect?
Currently are you or any member of your family applying for insurance
(g) receiving any medical treatment or medication, or on special diet or expecting to consult Yes
a doctor, in connection with any illness, injury, disability or impairment for which
symptoms are known, evident, or suspected?
At any time, have you or any member of your family applying for insurance
(i) been postponed, declined, or accepted subject to special terms by any insurance companyYes
for life insurance policy?
(k) is there any additional information relating to the health of you or any member of your Yes
family included in this form that you should in good faith disclose?

No
No
No
No

No
No

If you have answered "YES" to any of the questions above then complete the next section. If the space is
insufficient, please supply details separately.
13. DETAILED HEALTH STATEMENT
Details of any condition which caused incapacity for 10 days or more, and which have occurred within the last
five years:
Name
Date
Reason
Current situation

Details of any conditions which have necessitated specialist consultation, or hospital attendance either as an outpatient or in-patient, and which have occurred within the last five years:
Name
Date
Reason
Current situation

Details of any conditions or impairment which still exists or has left any residual effect that has necessitated
consultation with any doctor within the last five years:
Name
Date
Reason
Current situation

Details of any current medical treatment or medication, or special diet, or illness, injury, disability, or impairment
for which symptoms are known, evident, or suspected:
Name
Date
Reason
Current situation

Details of any insurance application which has resulted in cover being postponed, declined, or accepted subject to
special terms:
Name
Date
Reason
Current situation

Details of any additional information relating to health that you should in good faith disclose:
Name
Date
Reason
Current situation

14. DECLATRATION
I declare that the statements in this application are true and complete. This Application and declaration, together
with supplementary application declarations or disclosures made by me and the Employer shall be the basis of the
contract of the Plan.

Signature of Employee

Date