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    Primary Insured Information:
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    Nominee Information

    Relationship with primary member

    I hereby declare that, currently I am/ my family members insured under this policy are in Good Health and actively performing all day to day activities without any illness and disability. I am/ my family members insured under this policy are not receiving any treatment, have not treated or told to have any treatment for Cancer, Kidney, Stroke, Heart disease (Stanting/ Bipass Surgery), Liver Cirrhosis, Lung Disorder or HIV/AIDs related disease or any other physical impairment. I hereby certify that according to my knowledge and belief, all the above statements are true and that I have not withheld any relevant information. I agree that this declaration will be that basis of this insurance. I understand and agree that failure to disclose facts that affect the assessment of risk by the Insurance Company would invalidate the coverage.

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