Lic Form 680 Rev 87 PDF Details

Navigating through the maze of insurance forms can be a daunting task for anyone, and the LIC 680 form is no exception. Crafted under the Life Insurance Corporation Act of 1956, this form plays a crucial role in the revival of lapsed insurance policies, whether on a medical or non-medical basis. It requires the policyholder to provide a detailed personal statement regarding their health, which includes the full name and contact details of the life assured, alongside the policy and agent details. The form delves deeper, asking about past health issues, operations, accidents, or any diagnostic tests undertaken like ECGs or X-rays. It also probes into any previous attempts to revive an insurance policy and the current state of the policyholder's health. For policies under the Non-medical Scheme, specific details regarding height, weight, and the status of all policies issued or revived under this scheme are required. The form takes a comprehensive approach to understanding the policyholder's health and any changes that might affect the policy revival process. By declaring that the provided information is truthful, the policyholder agrees that these statements are foundational to the revival contract with the Life Insurance Corporation of India, emphasizing the importance of transparency in this process.

QuestionAnswer
Form NameLic Form 680 Rev 87
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameslic revival form 680 pdf, form 680 lic, lic revival form 680 how to fill, lic dgh form 680

Form Preview Example

(Established by the Life Insurance Corporation Act, 1956)

PERSONAL STATEMENT REGARDING HEALTH

F. NO. 680 ( Rev. 680 )

Date of Receipt _____________

Inward No. _____________

(Revival OF Lapsed Policies on both Medical & Non-Medical basis)

 

 

 

 

 

 

 

 

 

Agent’s Name :

 

Divl.

 

 

 

Branch Office:

 

 

Policy No

 

 

 

Office:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Full name of the Life Assured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full

 

Address1

 

 

 

 

 

 

 

 

 

 

 

Address2

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

Address3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

Phone/Mobile No

 

Occupation

 

 

 

 

 

 

 

 

 

 

Name of Employer

 

 

 

Length of

 

 

 

years

 

 

 

Service with him

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer

 

If 'Yes"

give

details of

 

 

 

 

 

 

 

 

ailment such as nature of

2. Since the date of your Proposal for the

'Yes' or 'No'

 

 

illness,

date

of onset,

above mentioned Policy:

 

 

 

 

 

 

 

 

duration of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

illness etc.

 

(a) Have you ever suffered from any

 

 

 

 

 

 

 

illness/disease requiring treatment for a

 

 

 

 

 

 

 

week or more?

 

 

 

 

 

 

 

 

(b) Did you ever have any operation,

 

 

 

 

 

 

 

 

accident or injury?

 

 

 

 

 

 

 

 

(c) Did you ever undergo ECG, X-Ray,

 

 

 

 

 

 

 

Screening, Blood, Urine or Stool

 

 

 

 

 

 

 

 

examination?

 

 

 

 

 

 

 

 

3. Has a proposal or an application for revival of a policy on your life made

 

to this or any other Office of the Corporation or any Insurer ever been:

 

 

 

 

 

 

 

 

 

 

 

 

(i) Withdrawn or dropped?

 

 

 

 

 

 

 

 

(ii) Accepted with an extra premium or lien?

 

 

 

 

 

 

 

(iii) Deferred or declined?

 

 

 

 

 

 

 

 

(iv) Accepted on terms otherwise than

 

 

 

 

 

 

 

those proposed?

 

 

 

 

 

 

 

 

If so, give details:

 

 

 

 

 

 

 

 

(b)Is any proposal or an application for revival of a. lapsed

 

 

 

policy on your life under consideration of this or any other

 

 

 

Office of the Corporation?

 

 

 

 

 

 

 

 

If answer

is 'Yes' give the

 

(i) Proposal No.

 

 

 

 

 

following details:

 

(ii) Policy No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revival of Lapsed Policy (Form 680).

 

 

 

 

 

 

Page 1 of 3

4. Are you at present in sound health?

N.B. - For Revivals under Non-medical scheme (Question Nos. 5 & 6)

5.

(i) State your height (without shoes)

cm.

 

(ii) Your weight (with thin clothes.)

kgs

6.State below, details of all your policies issued and/or revived under any of the Non-Medical Schemes of the Corporation:

Name of the Divl. Office

 

 

 

/Unit

Policy Number

Sum Assured

Status of the

Br. Office Servicing the

Policy

 

 

Policy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Females only:

7.Since the date of your (i) Have you been menstruating regularly?

proposal under the above

(ii) Have you had any

mentioned policy:

miscarriage/s?

 

(iii) Are you pregnant now?

 

(iv) State the date of last menstruation:

 

(v) State the date of last delivery:

 

DECLARATION

I……………

do hereby declare that the foregoing statements and answers are true and complete in every particular, and agree and declare that these statements and this declaration along with my Proposal for Insurance under the lapsed policy shall be the basis of the contract of revival of the lapsed policy between me and Life Insurance Corporation of India, and that if any untrue averment be contained therein, the said contract shall be absolutely null and void and all moneys which shall have been paid in respect thereof, shall stand forfeited to the Corporation.

And I further declare that if between the date of this declaration and the date of revival of the policy (i) any change in any occupation or any adverse circumstances connected with my financial position or the general health of myself or that of any member of my family occurs or (ii) a Proposal for assurance or any application for revival of a policy on my life made to any Office of the Corporation is pending or has been withdrawn or dropped, deferred or declined or accepted at an increased premium or subject to a lien or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to reconsider the terms of Revival of the Policy. Any omission on my part to do so shall render the Revival absolutely null and void and all moneys which shall have been paid in respect thereof, shall stand forfeited to the Corporation.

Dated at

on the

day of

(month) 20

Signature of Witness

Name :

Occupation :

& Address :

Signature or Thumb impression of the Life Assured

Revival of Lapsed Policy (Form 680).

Page 2 of 3

"If in this form, the answers to the questions and/or signature of the Life Assured are given in vernacular, then the Life Assured should declare in his own handwriting above his own signature that all questions were explained to him and that his replies were given after fully and properly understanding the same."

(1)This declaration should be made by the person filling in the form

Name

&Address Of the declarant

(1)I hereby declare that I have fully explained the above questions to the Life Assured and I have truthfully recorded the answers given by the Life Assured.

Signature

In case the Life Assured is Illiterate:

(2) The thumb impression of the Life Assured

(2) I hereby declare that I have explained

should be attested by a person of

the contents of this form to the Life

standing whose identity can easily be

Assured in

(language) and

established, but unconnected with, the

that I have read out to the Life

Corporation and this declaration

Assured, the answers to the

should be made by him:

questions dictated by the Life

 

Assured and that the Life Assured

 

has affixed his thumb impression

 

to this form after fully understanding'

Name

the contents thereof.

 

 

 

&Address Of the

declarant

Signature

Revival of Lapsed Policy (Form 680).

Page 3 of 3

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