IF REQUIRED ADDITIONAL COVER

GUARANTEED PAYMENT% OF SUM ASSURED PAID AT YEAR

ANOTHER GUARANTEED PAYMENT% OF SUM ASSURED PAID AT YEAR

GUARANTEED FINAL PAYMENT% OF SUM ASSURED PAID AT YEAR

GUARANTEED PAYMENT AT DEATH DUE TO NATURAL CAUSES

GUARANTEED PAYMENT AT DEATH DUE TO ACCIDENTAL CAUSES

HAVE YOU EVER HAD OR ARE AT PRESENT AILING FROM ANY:

(i) DISEASE OF EYES, EARS, NOSE, THROAT, GIDDINESS, EPILEPTICS OR OTHER FITS, POLIO OR ANY MENTAL ILLNESS OR PARALYSIS OR MULTIPLE SCLEROSIS OR COMA OR NERVOUS DISORDER?

(ii) SPITTING OF BLOOD, COUGH, PLEURISY, TUBERCULOSIS, BRONCHITIS, ASTHMA, CHRONIC LUNG DISEASE OR ANY OTHER DISEASE OF THE LUNGS?

(iii) HEART DISEASE, STROKE, BLOOD PRESSURE PROBLEMS, HYPER LIPIDEMIA, CHEST PAIN, ON EXERTION OR PRIMARY PULMONARY ARTERIAL HYPERTENSION?

(iv) CANCER, CARBUNCLE TUMOUR,CYST OR LEPROSY, DIABETES, FULMINANT HEPATITIS, KIDNEY OR LIVER DISEASE?

(v) JAUNDICE, GALL BLADDER DISEASE, PILES, FISTULA OR ANY STRICTURE, INDIGESTION, DIARRHOEA OR ABDOMINAL PAIN, GASTRO-INTESTINAL OR URINARY DISEASE?

(vi) GOUT,RHEUMATIC FEVER, RHEUMATISM OR ARTHRITIS OR MUSCULAR DYSTROPHY, RUPTURE OR HERNIA?

(vii) GONORRHEA, SYPHILIS, AIDS OR ANY OTHER SEXUALLY TRANSMITTED DISEASE?

(viii) ARE YOU SUFFERING FROM ANY DISABILITY/DEFORMITY, ILLNESS OR DISEASE NOT MENTIONED HEREIN?

(ix) HAVE YOU HAD ANY ACCIDENT OR HAD ANY INJURY?

(x) HAVE YOU TAKEN ANY X-RAY, ECG OR FLUROSCOPIC EXAMINATION OR UNDERGONE ANY MEDICAL INVESTIGATION OR SURGERY?

(xi) HAVE YOU BEING IN ANY HOSPITAL, NURSING HOME, ASYLUM OR SANATORIUM FOR OBSERVATION OR TREATMENT AS AN INPATIENT?

(xii) HAVE YOU EVER PASSED SUGAR, BLOOD, PUS OR ALBUMIN IN URINE/ HAVE YOU DONE ANY GENETIC TESTING?

DO YOU INDULGE IN OR HAVE EVER INDULGED IN:

(xiii) ALCOHOLIC DRINKS?

(xiv) NARCOTIC DRUGS OR SEDATIVES?

(xv) SMOKING CIGARETTES, CIGARS OR BEEDIE?

(xvi) CHEWING BETEL WITH TOBACCO AND/OR CHUNAM?

FAMILY MEDICAL HISTORY

ARE TWO OR MORE FAMILY MEMBERS (FATHER | MOTHER | BROTHER/S | SISTER/S) SUFFERING FROM ANY ONE OF THE ILLNESSES MENTIONED BELOW:

DIABETES, HYPERTENSION, HEART DISEASE, CANCER OR ANY OTHER PROLONGED DISEASE?

QUESTIONS RELATING TO COVID19

HAVE YOU EVER TESTED POSITIVE FOR THE NOVEL CORONAVIRUS (SARS-CoV-2/COVID -19)?

OR ARE YOU AWAITING THE RESULT OF A TEST WHICH HAS ALREADY BEEN SUBMITTED FOR THE NOVEL CORONAVIRUS?

OR HAVE YOU BEEN SERVING A NOTICE OF QUARANTINE FOR POSSIBLE EXPOSURE TO NOVEL CORONA VIRUS WITHIN LAST 30 DAYS?

I, the Main Proposer, do hereby jointly and severally declare and agree that:

(1) The foregoing answers have been given by me after fully understanding the questions, that the same are true in every particular and that I have not withheld any information.

(2) Hereby agree that this declaration together with this online proposal for life assurance and any other declarations or statements made or to be made to a medical examiner or to the Company in connection with this online proposal shall be the basis of the contract between me and the Sri Lanka Insurance Corporation Life Limited.

(3) I understand and agree that by submitting this proposal through online, I shall be bound by such statement/disclosures of material facts in the same manner and to the same extent, as if I have signed and submitted a written proposal for insurance to the company.

(4) I hereby confirm that the information, statements and declarations provided by me either electronically or otherwise are true and accurate and that all documents uploaded by me are valid and genuine and that I request Sri Lanka Insurance Corporation Life Limited to rely and act upon all such information, statement and declarations and documents provided by me.

(5)I confirm that the premium that will be paid by me is from my own source of income acquired through legal means or with authorization of the debit/credit card or payment gateway user.

(6) I hereby give my consent to the company to send e-policy document and any future correspondences related to this policy in e-document form. Further I consent to receiving my policy related information and communications through call, SMS, Email to the mobile number and email provided by me in the proposal form and agree that all communication sent to my mobile number and email as valid communication duly received by me.

(7) I acknowledge and agree that Sri Lanka Insurance Corporation Life Limited shall interview me via Microsoft teams/zoom video conference service, Whatsapp or any other video or audio method and record my voice, call and photograph for the purpose of identity verification and retain such information in accordance with legal and regulatory requirements. I am aware that such information provided therein, shall become part and parcel of the policy contract. I further agree to ensure a clear, unobstructed view of my identity during the video conference call and remove anything that may obscure my face. In addition, I will co-operate with full completion of Sri Lanka Insurance Corporation Limited’s established non face-to-face onboarding procedure.

(8) I also give consent to the authorized representative of Sri Lanka Insurance Corporation Life Limited to verify the personal information provided by me with the Department for registration of Persons database, for identification purpose.

(9) I confirm that I will be providing you with my personal data and hereby expressly consent to the use of such data to provide insurance products & services and to facilitate other related services offered by you. This includes express permission to share the personal data information with service providers and authorized representatives of Sri Lanka Insurance Corporation Life Limited.

(10) The undersigned hereby consents to the collection, use and transfer of personal data as mentioned in this paragraph. The undersigned understands that the Company holds certain personal information about him/her including Full name, Address, Date of Birth, Gender, National Identity Card/Passport Details, Job title, Telephone Number, Email address, Educational & professional Experience, Business Activities, Travel & expenses information, Financial Details (e.g. Credit/Debit Card & Bank Account Details etc.), Identification checks & background vetting and Other Information including family life. The undersigned further understand that the Company holds special categories of personal data concerning health and such other information which may fall within the definition of “special categories of personal data”, as defined in the Data Protection Act, No. 09 of 2022. The undersigned further understands that it may be necessary for the purposes of the relationship with the company, to share data with Reinsurers, Actuaries and such other required parties for the purpose of assessing the risk, risk assessment and for any other such related matters. The undersigned authorizes the Company to receive, possess, process and transfer the data for the purpose of the pre insurance contract evaluation and for the purpose of servicing insurance contracts

(11) I undertake to duly inform the Sri Lanka Insurance Corporation Life Limited of any charge in the state of health, occupation, avocation, residence and/or any other change to the details provided in this proposal of the Main Proposer between the date of this proposal and the date of commencement of the assurance and also to pay any extra premiums that may be imposed on account of health, occupation, avocation and/or residence.

(12) If, I decide to withdraw this proposal for any reason before it is accepted, I agreed to the deduction of the cost incurred by the company for medical examination, laboratory reports and service fee from the initial payment paid to the Company.

(13) Notwithstanding the provisions of any law, usage, custom or convention for the time being in force prohibiting any physician, surgeon, medical practitioner or medical attendant from divulging any knowledge or information acquired by him in attending upon or examining or treating a person, I, my heirs, executors, administrators and assigns or any other person who shall have claim or interest of any kind whatsoever in the policy issued on the basis of the foregoing answers hereby agree that any physician, surgeon, medical practitioner or medical attendant who has attended upon or examined or treated the Main Proposer who may here after attend, examine or treat the Main Proposer for any ailment or illness shall be at liberty to divulge, any knowledge or information regarding the state of health of the Main Proposer which he may have acquired whether before or after the policy is issued by the Company to the Company, its officers and legal advisers or to any Court of Law.

(14) Further, I authorize any representative or a Medical Consultant of the Sri Lanka Insurance Corporation Life Limited to peruse or obtain the Bed Head Ticket or any other clinical notes for any Private or Government Hospital, Clinic, Nursing Home, Asylum or Sanatorium, if necessary.