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LIFE INSURANCE CORPORATION OF INDIA Form No. LIC03 - 013 SPECIAL BIO-CHEMICAL TESTS 13 SBT-13 Zone Division Proposal No. Agent/D. O. Code Introduced by Full Name of Life to be assured Age/Sex Branch Type of Test Fasting Blood Sugar Method Total Cholesterol High Density Lipid HDL Low Density Lipid LDL S. Triglycerides S. Creatinine Blood Urea Nitrogen BUN S. Proteins a Albumin b Globulin AG Ratio S.Bilirubin a Direct b Indirect Total SGOT AST SGPT ALT GGTP GGT S. Alkaline Phosphatase HbsAg Australia antigen Elisa for HIV Method Actual Reading I declare that the person examined signed affixed his/her thumb impression in the space earmarked below in my presence and I am not related to him/her or the Agent or the Development Officer. LIFE INSURANCE CORPORATION OF INDIA Form No* LIC03 - 013 SPECIAL BIO-CHEMICAL TESTS 13 SBT-13 Zone Division Proposal No* Agent/D. O. Code Introduced by Full Name of Life to be assured Age/Sex Branch Type of Test Fasting Blood Sugar Method Total Cholesterol High Density Lipid HDL Low Density Lipid LDL S* Triglycerides S* Creatinine Blood Urea Nitrogen BUN S* Proteins a Albumin b Globulin AG Ratio S*Bilirubin a Direct b Indirect Total SGOT AST SGPT ALT GGTP GGT S* Alkaline Phosphatase HbsAg Australia antigen Elisa for HIV Method Actual Reading I declare that the person examined signed affixed his/her thumb impression in the space earmarked below in my presence and I am not related to him/her or the Agent or the Development Officer. Dated at on the Signature of the L*A. day of 200 at a*m*/p*m* Pathologist s name Address Qualification Proposer was identified on the basis of SIGNATURE OF PATHOLOGIST. O. Code Introduced by Full Name of Life to be assured Age/Sex Branch Type of Test Fasting Blood Sugar Method Total Cholesterol High Density Lipid HDL Low Density Lipid LDL S* Triglycerides S* Creatinine Blood Urea Nitrogen BUN S* Proteins a Albumin b Globulin AG Ratio S*Bilirubin a Direct b Indirect Total SGOT AST SGPT ALT GGTP GGT S* Alkaline Phosphatase HbsAg Australia antigen Elisa for HIV Method Actual Reading I declare that the person examined signed affixed his/her thumb impression in the space earmarked below in my presence and I am not related to him/her or the Agent or the Development Officer. Dated at on the Signature of the L*A. day of 200 at a*m*/p*m* Pathologist s name Address Qualification Proposer was identified on the basis of SIGNATURE OF PATHOLOGIST.

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Keywords relevant to chemical test report format

  • proposer
  • HBsAg
  • SBT-13
  • triglycerides
  • LIC03
  • HDL
  • GGTP
  • affixed
  • Phosphatase
  • urea
  • lipid
  • Pathologists
  • ALBUMIN
  • bilirubin
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