HAZARDOUS HOBBY Q-2.
Hazardous Hobby Questionnaire regarding paragliding, skydiving & bungee jumping
We thank you for applying for an HDFC Life Insurance Policy. To enable us to assess your
application, kindly send this Hazardous Hobby Questionnaire answered by the Life to be Assured and
duly signed by the Life to be Assured and Proposed Policy Holder, if any.
Application No / Proposal No
Name of Life to be Assured
1) Kindly tick on hazardous sports you are involved in. Paragliding
Skydiving
Bungee jumping
2) Are you involved in paragliding?
Yes
If yes, kindly answer the following questions. No
If no, refer to question no. (3), (4), (5) and (6).
2.a) Are you a member of any professional association? Yes / No
If yes, kindly name the association.
2.b) Please specify the number of paragliding flights per
year.
3) Are you involved in skydiving?
Yes
If yes, kindly answer the following questions. No
If no, refer to question no. (4), (5) and (6).
3.a) For how many years you have been participating in
skydiving?
3.b) How many jumps have you made till date?
3.c) How many jumps per year do you intend to take in
future?
3.d) Do you expect to participate in any skydiving Yes / No
competitions or record attempts?
If yes, please mention the nature of the jump i.e.
static line or free fall.
4) Are you involved in bungee jumping?
Yes
If yes, kindly answer the following questions. No
If no, refer to question no. (5) and (6).
4.a) Please specify the number of jumps that you
undertake per year.
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4.b) Are you a jumpmaster? Yes / No
5) Have you met with any accident on account of Yes / No
hazardous sports?
If yes, kindly mention the date of accident and extent
of injuries sustained.
6) Do you suffer from any kindly of health ailment on Yes / No
account of hazardous sports?
If yes, mention exact diagnosed condition.
An incomplete Questionnaire will not be considered valid.
Declaration of Life to be Assured:
I agree and understand that the information given herein is true and complete in all respects and will form an
integral part of the proposal made by me for an insurance policy from HDFC Life Insurance Company Limited and
that failure to disclose any material fact known to me may invalidate the contract.
Signature/thumb impression Date:…………………………….
(Life to be Assured) Place:………………………
Signature/thumb impression
(Proposed Policy Holder if different Date:……………………………
from Life to be Assured) Place:………………………….
In the case of thumb impression\ signature in vernacular language:
In case of thumb impression of the Life to be Assured the same should be attested by a person of standing whose
identity can be easily established, but unconnected with the Company and this declaration should be made by
him.
I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language
and have truthfully recorded the answers provided to me and that the Life to be Assured has signed /affixed
thumb impression(s) above after fully understanding the contents thereof.
Signature Date:……………………………
Place:………………………….
Name and address of the declarant
HDFC Life Insurance Company Limited. CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860-267-9999 (Local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email - service@hdfclife.com | nriservice@hdfclife.com (For NRI customers only) | Visit - www.hdfclife.com
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