NATIONAL INSURANCE COMPANY LIMITED

3, MIDDLETON STREET, KOLKATA 700 071

PERSONAL STATEMENT REGARDING HEALTH

CONFIDENTIAL

Ref. No. ……………………………….

1) Name in full (Block letters) …………………………………………………………………………………

2) Father’s name in full …………………………………………………………………………………………

3) Date of Birth and Age …………………… Yrs. ………………………………….. Months ……………

4) Marital Status : (Married / Single)………………. Children……..Son……… Daughter…………

( In the case of female, following particulars be furnished)

i) Husband’s full name : ……………………………………….

ii) His occupation : ……………………………………….

5) Have you lived during the last three years with any
Person suffering from tuberculosis, leprosy or any
Other infectious disease? If so, give details: …………………………………………………………

6) What has been your usual state of health? Do you

Suffer from mental disability at any time? ………………………………………………………...

7) Have you any bodily defect or deformity? If so, give details:

……………………………………………………..

8) Have you consulted a medical practitioner within

the last two years ? If so, give details: ………………………………………………………

Answer all questions : Put ( √ ) Mark in the Column ‘Yes’ /’No’

Sl. No. Question Yes No

Are you on any prolonged medication ?
9. If Yes, specify :

Are you allergic to any medicine ?

10. If Yes, specify :

11 Do you suffer from any of the following :

 High Blood Pressure

 Heart Disease
 Tuberculosis
 Stroke(Paralysis due to Haemorrhage in brain)
 Diabetes
 Mental illness
 Cancer
 Any other disease, please specify :
12. Do you take alcoholic beverages / intoxicants ?
Contd to P/2

:2:
 Do you smoke or take tobacco ?
13
If yes, how much every day ?
14 Do you have fainting spells ?
Do you become unusually short of breath when you walk upon flight
15
of stairs ?
Have you had a cough that started in the last 6 months & remained
16
more than a month ?
17 Have you ever vomited or coughed out blood ?
18 Do you have weakness or paralysis of either of your arms or legs ?
Do you ever feel so depressed that if interferes with your jobs or with
19
your doing house work ?
Do you feel that you need medical or psychiatric help because of
20
nervousness?
Have you ever been rejected in Pre-Employment Medical
21.
Examination?
If yes. Name of the company , where you got appointed :
Do/Did any of your family member(s) suffer(ed) from any of the
following :
 High Blood Pressure
 Heart Disease
22.  Tuberculosis
 Stroke(Paralysis due to Haemorrhage in brain)
 Diabetes
 Mental illness
 Cancer
23 Do you have Hernia/ Piles / Hydrocele ?
24 Please specify significant information , if any, not covered above :

25. Have you ever passed blood or pus, in the urine? ………………………………………………

26. Were you medically advised to have a change of place for health reasons ? If so, give reasons and state
when and how long . ……………………………………………………………………

27. a) Did you ever have any operation, accident or injury ? ……………………………………………………………

b) Have you ever had an electrocardiogram X-Ray or screening, blood , urine or stool examination ?
…………………………………………………………..

c) Have you ever been in any hospital, for Checkup, observation, treatment or any operation?
………………………………………………………..………………………………………………

28. FOR FEMALE CANDIDATES ONLY

a) Have the menstrual periods always been regular and painless and are they so now?
……………………………………………...................................
b) Are you pregnant now? If yes, expected date of delivery.
……………………………………………..................................

DECLARATION

I,…………………………………………………………………………………………., hereby declare that the information given

by me in this statement is true and correct and that if any untrue information is found to be contained
therein, I shall be liable for such action as the Company deed necessary .

Dated at ………………………………… this ………………………………….. day of 2015

……………………………………………..
SIGNATURE OF THE CANDIDATE
…………………………………………………………………..
SIGNATURE OF THE MEDICAL EXAMINER
 NATIONAL INSURANCE COMPANY LIMITED
3, MIDDLETON STREET, KOLKATA 700 071
Confidential

MEDICAL REPORT
(To be completed by the Doctor Appointed by our Office)

Ref. No. ………………………………………..

Name of the candidate ………………………………………………………………………

1. (a) Is the general appearance of the candidate healthy?

………………………………………………………………...

(b) Are there any physical defects or deformities ?

……………………………………………………………………

(c) Describe personal marks or peculiarities by which he/ she may be identified .

……………………………………………………………………..

2. Is there any evidence of skin disease, Vericoaevains, enlarged Joints, marked anaemia?

………………………………………………………………………

3. Following examinations to be carried out:

(a) Weight and Height Weight …………….. Kgs. Height…. ……………….Cms.

(b) Condition of Eyes, Ears and
Throat (Blindness, Deafness,
Septic Tonsils etc.) …………………………………………………………………….

(c ) Condition of Chest. Any tuberculosis of lungs, bronchitis or asthma

……………………………………………………………………

1. Chest (Over nipples stripped) On complete expiration …………………………………Cms.

2. Abdomen (Over naval stripped) On full inspiration ………………………………………. Cms.

(d) Condition of heart – any valvular Disease,

enlargement any personal
History of rheumatism, chest pain,
Hypertension, coronary thrombosis. ……………………………………………………………………….

(e) Pulse …………………………………………………….

(f) Blood Pressure to be recorded In all cases.

Systolic …………………………….mm. Hg.
Diastolic ……………….............. mm.Hg.

(g) Condition of digestive tract. any history of ulcer or

stomach or duodenum. Any signs of its presence.
Any enlargement of
liver or spleen.
Sp.Gravity SugarAlbumen Deposits
(h) Urine – to be examined in all cases for
aalbumen and sugar
(i) Haemogram: Blood Group ______ Rh factor _______ Hb________ TLC_______ RBC__________
DLC – P L E M B Platelets Count______________
Blood Urea ___________ S/Creatinine_____________
Blood Sugar –F_________ S/uric acid__________
Contd to P/2
 :2:

(j) X-Ray Chest ________________________

(k) In all cases examine for inguinal hernia and if present whether a well-fitting truss is regularly
worn.

(l) Inquire into personal history of accident, injury, operation fainting fits, paralysis etc.

4. Is he/she, in your opinion, mentally and physically it for appointment in the General Insurance Industry?

…………………………………………………………………….

5. To be filled in by female candidates only in the presence of the Medical Examiner:

(a) Are you married? …………………………………………………………………….

(b) If so, please state

(i) Husband’s name in full &

Occupation ……………………………………………………………..
(ii) Are you pregnant? ………………………………………………………………….
(iii) State the number of children,
If any, and their present age …………………………………………………………………

I hereby certify that I have this day examined the above candidate personally, in private and have recorded in
my own hand the true and correct findings. I declare that I am not related to the party. In our opinion, he/she
is mentally and physically fit for appointment in General Insurance Industry.

Dated …………………….. this …………………………………. Day of ……………………………………2015

…… …… ……………………………...
SIGNATURE OF THE MEDICAL EXAMINER
…………………………………………………………

SIGNATURE OF THE CANDIDATE

********************************************************************************************************************

PARTICULAR OF THE MEDICAL EXAMINER

Signature …………………………………………………………………

Medical Examiner’s Code No. …………………………………………………………… (Allocated by the

LIC of India) …………………………………………………………… (Association’s RMP. NO.)
…………………………………………………………..

Name in full and address ………………………………………………………….

…………………………………………………………

Medical Degree ……………………………. Name of the University ……………………………………………………

Year in which the Degree obtained …………………………… RMP..............................................................