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Get India National Insurance Company Medical Request And Self Declaration Form 2011-2024

The Passenger: MEDICAL HISTORY (A) TO BE COMPLETED BY THE PROPOSER PLEASE ANSWER THE FOLLOWING QUESTION WITH YES OR NO (A DASH IS NOT SUFFICIENT) AND GIVE FULL DETAILS: 1. 2. 3. 4. 5. 6. Are you in good health and free from physical and mental disease or infirmity? Have you ever suffered from any illness or disease up to the date of making this proposal? Do you have any physical defect or deformity? Have you ever been admitted to any hospital / nursing home / clinic for treatment.

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