Health Declaration Template

A health declaration template is a readymade health declaration form which is used by organisations or individuals. Through templates, one gets the flexibility to change the information according to need and suitability. The templates of this kind are framed in such a way that users can quickly and easily fill their personal details to customise the template as per their specifications. Thus any health declaration template is a time saving as well as energy saving medium to draft a health declaration document with a proper format and correct content composition. If you are searching for a sample of a health declaration template, then just scroll down.

“You can Download the Free Health Declaration Template form, customize it according to your needs and Print. Health Declaration Template is either in MS Word, Excel or in PDF.”

Sample Health declaration template

Health declaration template

Download Health declaration template

Details of the life to be insured

Full name: _________ [write full name]

Sex: ________ [male/female]

Date of birth: _____________ [dd/mm/yy]

Age: ________________ [write age as on last birthday]

Nationality: _____________ [write nationality]

Life style information:

Has any declaration for health by this company been previously declined, deferred or accepted: _____ [yes/no]

Have you participated in/participate in diving, mountain/rock climbing, vehicle or other such activity: ______ [yes/no]

Have you used/do you use cocaine or any other stimulants, LSD, Marijuana or any other narcotic: _____ [yes/no]

Do you consume alcohol? _____ [yes/no]

Have you ever been advised by a physician to stop drinking or smoking? ________ [yes/no]

Family physician details

Name: __________ [name of the family doctor/physician]

Address: ___________ [address of the family physician]

Contact number: ________ [write down the doctor’s contact number]

Declaration by the life to be insured

As per section ___ [section number] of insurance act____ [mention insurance act number], I understand and agree that the answers and statements made on this health declaration including any medical examination and any other documents are full and complete and also true in every particular and will form the basis of any contract why may arise….____________ [and so on give the complete declaration…]

Dated: ____________ [mention the date of the health declaration in dd/mm/yy format]

Signature of the life to be insured: ___________ [signature of the person for whom the declaration is drafted]

Category: Health Templates

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