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Quotation

Quotation

Years

Results

Life and Health Benefits

Insurance Cover LKR Premium LKR
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Sub Total
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Retirement Benefits

Illustrated maturity benefit assuming 9% Contribution
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Total Premium
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Registration

Registration

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Questions

Previous Policies

Yes No
Do you have any Life Insurance policies or have you submitted any proposal to any other Insurer for Life Insurance cover?
Have you ever had an application for Life Assurance Declined, Postponed or Accepted with special terms?

Particulars of Illness

Are you at present suffering from any of the following diseases or disorders or have you had any medical treatment or undergone any surgery including tests, scans or X-Rays for any of the following diseases or medical conditions?
Yes No
Diabetes
Any disease of the eyes, ears,nose or throat
Any disorders of the blood
Any disease/disorder of the spine,bones or joints
Any sexually transmitted diseases
Any disorder of the skin(chronic or congenital) or lymph glands
Any Congenital disorders,deformities or anomalies
Any other illness, surgery or injury
High Blood Pressure
Elevated Cholesterol
Any disorder of the Heart or circulation
Any form of Cancer, Tumour or Growth
Any disorder of Kidneys or Genito-Urinary System
Any disorder of the brain or Nervous system including mental depression
Any disease of the Respiratory system or lungs
Any disorders of the Gastro-Intestinal or Digestive system

Habits

Yes No
Do you consume or have you consumed liquor?
Do you smoke or have you smoked?
Do you take or have you taken narcotic drugs or sedatives?

Family History

Yes No
Is/Are there any immediate relative/s who has/have died or diagnosed with the following illnesses prior to 65 years of age ?
  • Cardio Vascular disorder
  • Diabetes
  • Renal failure
  • Cancer
  • Genetic disorder

Hazardous Occupations

Yes No
Do you engage in or do you have any intention of taking part in any form of Motor sports, Climbing, Diving, Flying a private air craft, Sky diving, Gliding etc..?
Do you have any intention of travelling abroad ?
Do you have or had any kind of threats on your life ?
Have you been convicted of any criminal offence or Illegal activity ?
Was there any criminal case against you in a Court of Law or Is there any case pending or under investigation against you ?

Beneficiaries

Beneficiaries

Beneficiary Full Name Relationship Date of Birth Beneficiary NIC Percentage
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Declaration of Payments

Declaration of Payments

Important: The below section must be read by the Life to be Assured/Life Assured and signed and dated at the time of policy delivery.

I do hereby declare and agree that:

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

This declaration together with this 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 proposal shall be the basis of the contract between me and Ceylinco Life Insurance Limited.

The Privileges,Conditions and Exclusions of the life policy and supplementary benefits therein on which the assurance will be granted, will be part of the policy.

I undertake to duly inform Ceylinco Life Insurance Limited of any change in my state of health, occupation, avocation and/or residence 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.

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

I ,my heirs, executors, administrators and assigns hereby agree that any physician, surgeon,medical practitioner or medical attendant who has attended upon or examined or treated me or who may hereafter attend,examine or treat me for any ailment or illness shall be at liberty to divulge, any knowledge or information regarding the state of health of mine which 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.

I authorise any representative or a Medical Practitioner of Ceylinco Life Insurance Limited to peruse or obtain the Bed Head Ticket or any other clinical notes from any Private or Government Hospital, Nursing Home,Asylum or Sanatorium and also authorise to obtain information from any other insurer.

Further I do hereby agree to sign any declaration made over the phone to the Ceylinco Life Insurance Limited, during the negotiation of the contract prior to the acceptance of the contract and also do hereby agree that the statements made by me are part of the contract entered into between me and the Ceylinco Life Insurance Limited.

Notice

You will be required to complete the payment section within a stipulated time frame or provide an additional security code depending on your credit card. Therefore, if you are using the online payment method for the first time, kindly contact your bank for further instructions.

Still if you are unable to make the payment or if the payment fails, please do not hesitate to contact the Ceylinco Life Call Centre on 0112 461 461.

Thank You!