I/We warrant that the above statement and particulars are true, and I/we hereby agree that this declaration shall be held to be promissory and shall form the basis of the Contract between me/us and Green Delta Insurance Co. Ltd. And I/We undertake that the Car or Cars to be insured shall not be given by any who to my/our knowledge has been refused any Motor Vehicle insurance or continuance prescribed by the Scheme therein.
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 (Stenting/ Bypass Surgery), Liver Cirrhosis, Lung Disorder or HIV/AIDs related disease or any other physical impairment. I hereby certify that according to my best 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 the basis on which the eligibility of policy shall be determined. I understand and agree that failure to disclose facts that affect the assessment of risk by the Insurance Company would render the coverage invalid