DECLARATION OF HEALTH
CERTIFICATE NUMBER ________________________
   
I CONFIRM TO THE BEST OF MY KNOWLEDGE AND BELIEF
A        
That all Persons to be insured are in good health and free from any physical defect or infirmity and that during the past twelve months have suffered no illness or accident. **
B         
That there has been no material alteration in the facts last disclosed in connection with this insurance which could affect Insurers’s views about the cover given or the premium charged. **
C        
That none of the Persons to be insured have visited their doctor or any other medical practitioner during the last twelve months. **

** If not so, Please give details:

NAME_____________________________________________(BLOCK CAPITALS)

SIGNED_____________________________________________________________

(Signature of principal insured person or company signatory on behalf of all insured persons)

DATE__________________ 

   AGE OF INSURED PERSONS                           YEARS
                 YEARS
                 YEARS
                 YEARS

PLEASE ENSURE THAT THIS INFORMATION IS COMPLETED AND RETURNED TO THE ISSUING AGENT PRIOR TO THE RENEWAL DATE.

By viewing our pages, you agree to our legal policy. Problems or queries? Contact us here