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Both pages(if exist) of your provided document are required
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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.
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