Are you looking for a quick and easy way to understand Regulation form 680 Rev 87? Look no further. In this blog post, we'll provide an overview of the Lic Form 680 Rev 87, covering everything from its purpose to any steps you need to take in order to correctly complete the form. Whether you are completing the form for yourself or on behalf of someone else, we will give you all the knowledge and resources necessary to ensure that your process is as stress-free as possible. So let's get started by taking a closer look at Lic Form 680 Rev 87!
Question | Answer |
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Form Name | Lic Form 680 Rev 87 |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | lic revival form 680 pdf, form 680 lic, lic revival form 680 how to fill, lic dgh form 680 |
(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 &
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Agent’s Name : |
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Divl. |
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Branch Office: |
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Policy No |
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Office: |
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1. Full name of the Life Assured |
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Full |
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Address1 |
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Address2 |
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Address |
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Address3 |
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Email Address |
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Phone/Mobile No |
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Occupation |
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Name of Employer |
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Length of |
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years |
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Service with him |
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Answer |
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If 'Yes" |
give |
details of |
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ailment such as nature of |
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2. Since the date of your Proposal for the |
'Yes' or 'No' |
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illness, |
date |
of onset, |
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above mentioned Policy: |
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duration of |
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illness etc. |
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(a) Have you ever suffered from any |
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illness/disease requiring treatment for a |
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week or more? |
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(b) Did you ever have any operation, |
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accident or injury? |
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(c) Did you ever undergo ECG, |
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Screening, Blood, Urine or Stool |
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examination? |
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3. Has a proposal or an application for revival of a policy on your life made |
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to this or any other Office of the Corporation or any Insurer ever been: |
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(i) Withdrawn or dropped? |
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(ii) Accepted with an extra premium or lien? |
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(iii) Deferred or declined? |
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(iv) Accepted on terms otherwise than |
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those proposed? |
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If so, give details: |
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(b)Is any proposal or an application for revival of a. lapsed |
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policy on your life under consideration of this or any other |
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Office of the Corporation? |
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If answer |
is 'Yes' give the |
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(i) Proposal No. |
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following details: |
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(ii) Policy No. |
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Revival of Lapsed Policy (Form 680). |
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Page 1 of 3 |
4. Are you at present in sound health?
N.B. - For Revivals under
5. |
(i) State your height (without shoes) |
cm. |
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(ii) Your weight (with thin clothes.) |
kgs |
6.State below, details of all your policies issued and/or revived under any of the
Name of the Divl. Office |
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/Unit |
Policy Number |
Sum Assured |
Status of the |
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Br. Office Servicing the |
Policy |
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Policy |
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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? |
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(iii) Are you pregnant now? |
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(iv) State the date of last menstruation: |
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(v) State the date of last delivery: |
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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 |
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should be attested by a person of |
the contents of this form to the Life |
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standing whose identity can easily be |
Assured in |
(language) and |
established, but unconnected with, the |
that I have read out to the Life |
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Corporation and this declaration |
Assured, the answers to the |
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should be made by him: |
questions dictated by the Life |
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Assured and that the Life Assured |
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has affixed his thumb impression |
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to this form after fully understanding' |
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Name |
the contents thereof. |
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&Address Of the
declarant |
Signature |
Revival of Lapsed Policy (Form 680). |
Page 3 of 3 |