TataAIA/NB/DM/83.
Asthma Questionnaire
Ramavtar Jangid
Name Of Proposed Insured: ........................................................................................................................
Policy no.: .................................................................................... 24-09-2022
Dated: ................................................
1) Date of first occurrence?
When I was 10 years old.
.......................................................................................................................................................
2) Name of main doctor attended for Asthma?
Dr. Pramod Bagul
........................................................................................................................................................
3) Date you last attended the doctor for this condition?
First and last when I was 10 years old.
...........................................................................................................................................................
4) a) Do you still receive treatment or suffer from any symptoms? Yes No
If No, then how long has it been since you have ceased all treatment and have been free of all
symptoms?
______year _______month
There is no treatment, I take rotocaps inhaler as and when required.
............................................................................................................................................................
5) Please can you provide details of the medication prescribed, to include past and present
medication, frequency, duration and dosage?
Past: ..................................................................................................................................
AEROCORT ROTOCAPS
Current: .................................................................................................................................
If you currently use any medication, please indicate what medication you use now, please answer
Yes or No to each of the following
Yes No
A cortisone or steroid inhaler
A bronchodilator spray
An anti-inflammatory spray
Cortisone tablets
If Yes, how many doses do you use each day :
1 2 3 4 5 >5
Remark:I rarely need this medicine (usage: 5-6 times in a year not daily).
6) Have you ever been admitted to hospital for treatment of your asthma? Yes No
If Yes, how many times in the past 5 years:
1 2 3 4 5 >5
Tata AIA Life Insurance Company Limited
(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Oct/217
TataAIA/NB/DM/83.1
7) When did you suffer from the symptoms of asthma?
On climate change, when it's the start of winter.
.............................................................................................................................................................
8) Have you missed more than 5 continuous days from your job, (or school for children) in the last 3
years due to asthma? Yes No
If Yes, please mention the period
………………………………………………………………………….............................................
9) Please provide copies of any medical reports you may have like Chest X-ray, Pulmonary
function test report or any other investigation report if any
No reports were taken at any point of time. since its a very mild symptoms.
.............................................................................................................................................................
10) Do you smoke cigarettes Or consumed tobacco in any form? Yes No
If Yes, how many per day
............................................................................................................................................................
I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.
Signature of Proposed insured:______________________ 24-09-2022
Date:____________________
Signature of Applicant:______________________ Date:____________________
(If applicant is different from the proposed insured)
VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.
I__________________ holding ______________(ID card type) with number __________(ID card
number) hereby declare that I have explained the contents of this declaration to the Proposed
Insured/Applicant in ________________ language and that the Proposed Insured/Applicant has affixed
his/her signature/thumb impression after fully understanding the contents thereof.
________________________________ _____________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature
Tata AIA Life Insurance Company Limited
(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Oct/217
