1. Please provide details of your current residency and residential status including information of
duration of stay by visa etc, if appropriate.
______________________________________________________________________________
__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Please provide details of your previous and future residence and travel (excluding holidays of
less than 4 weeks) :
3. Please provide a brief description of your occupational duties and/ or any other activities you
will participate while traveling or residing abroad.
______________________________________________________________________________
______________________________________________________________________________
4. Do you expect to spend the majority of your time in major / large cities? Yes No
If NO, please provide the name of the town/ region and details of your likely accommodation,
availability of medical facilities and travel arrangements (e.g. light aircraft, boat etc.) :
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
________________________________________________________________________
5. Please give details of any medical treatment or surgery you have received while residing
overseas.
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
________________________________________________________________________
6. Please provide any additional information regarding your residence and travel which you feel
may be helpful in processing your application.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I declare that the answers I have given are, to the best of my knowledge, true and I have not
withheld any material information that may influence the assessment of acceptance of this
proposal.
I agree that this form will constitute part of my proposal for life assurance and that failure to
disclose any material fact known to me may invalidate the contract.
VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.
I__________________ holding ______________(ID card type) with number __________(ID card number)
hereby declare that I have explained the contents of this declaration to the Proposed Insured/Applicant in
________________ language and that the Proposed Insured/Applicant has affixed his/her signature/thumb
impression after fully understanding the contents thereof.
________________________________ _____________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature