Form 680 - Personal Statement Regarding Health Page 3
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3"If in this form, the answers to the questions and/or signature of the Life Assured are
given in vernacular, then the Life Assured should declare in his own handwriting above his
own signature that all questions were explained to him and that his replies were given after
fully and properly understanding the same."
(1)This declaration should be made by the
(1) I hereby declare that I have fully
person filling in the form
explained the above questions to the
Life Assured and I have truthfully
recorded the answers given by the
Life Assured.
Name
& Address
Signature
Of the
declarant
In case the Life Assured is Illiterate:
(2) I hereby declare that I have explained
(2) The thumb impression of the Life Assured
the contents of this form to the Life
should be attested by a person of
Assured in
(language) and
standing whose identity can easily be
that I have read out to the Life
established, but unconnected with, the
Assured,
the
answers
to
the
Corporation and this declaration
questions
dictated
by
the
Life
should be made by him:
Assured and that the Life Assured
has affixed his thumb impression
to this form after fully understanding'
the contents thereof.
Name
& Address
Of the
declarant
Signature
Revival of Lapsed Policy (Form 680).
Page 3 of 3
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